Treatment
Of AIDS
Since the
mid 1990's AIDS treatment has been improved substantially by applying the principles
that came out of AIDS-research. Treatment should be monitored by an AIDS center,
if at all possible. This way the patient can be certain that the latest knowledge
about AIDS treatment is incorporated into the treatment regimen. The principals
of treatment are as follows.As the HIV virus reprograms the infected cells
(CD4 cells, endothelial cells, monocytes and brain cells) to produce new HIV RNA
virus copies at a high rate, the treatment is directed against this new RNA virus
synthesis. This is done by combining two antiretroviral drugs inhibiting HIV reverse
transcriptase with one protease inhibitor, which is directed against HIV protease.
This combination
is known as the "cocktail" against AIDS. It has to be taken regularly
in order to gradually starve the HIV virus. Unfortunately, there are many possible
treatment failures. Most commonly it is because patients get tired of swallowing
pills or of the side-effects, but fail to seek the advice of the treating physician
who could switch them to another medication that may be more tolerable. It could
also be that resistant strains are developing. The treating physician can monitor
for all of this by checking the plasma HIV RNA levels in the blood. Any level
of more than 400 copies per milliliter is now accepted by many AIDS experts to
mean that treatment needs to be stepped up after fist checking that the patient
had taken the medicines regularly (Ref. 1, p. 1321 and Ref. 2, p. 7).
| Some drugs directed
against HIV | | Generic
name: | Brand name: | Comments: |
| Zidovudine | Retrovir | can
lead to anemia and low white blood count |
| Lamivudine | Heptovir
| side effect :reversible peripheral neuropathy
and pancreatitis | | Stavudine | Zerit
| side effect :reversible peripheral neuropathy
| | Indinavir | Crixivan
| protease inhibitor; can lead to kidney stones |
| Ritonavir | Norvir | protease
inhibitor | | Saquinavir | Fortovase | protease
inhibitor | | Nelfinavir | Viracept | protease
inhibitor | | Nevirapine | Viramune | can
cause skin rashes | | Delavirdine | Rescriptor | can
cause skin rashes | | Enfuvirtide | Fuzeon | Fusion
inhibitor, a newer drug | If the initial
three drug cocktail is not effective in reducing the viral load, then the specialist
has several other options of treating. One option is to increase the number of
drugs in the cocktail, another to change the drugs to some of the newer drugs
that would cover for resistant strains. The emergence of resistant strains
will always be a problem with treatment of AIDS as there is such a huge turnover
of viral copies in the beginning of the disease where mutagenesis will create
small subpopulations of resistant HIV substrains, particularly in the presence
of antiviral drugs. With the introduction of the protease inhibitors there has
been a remarkable improvement in survival rates. However, despite the introduction
of yet a new class of antiviral drugs in the form of an HIV-1 infusion inhibitor
(Fuzeon or T20) it is clear that resistance will likely always remain a limiting
factor (Ref. 5). Overall this has led to a 20 to 25% survival advantage, but costs,
injection site reactions and the need for twice per day injections by the patient
lead to a 10% discontinue rate. Here is a website that lists the latest
on HIV treatment and research: http://www.cdcnpin.org/scripts/hiv/index.asp
The phone number of the CDCNational AIDS Clearinghouse is 1-800-458-5231
(Ref. 2, p.7). Apart from treatment of the HIV virus the physician must
address the multiple possible opportunistic infections. The worst of them might
be tuberculosis, which has to be treated like it is listed under this disease.
Candidiasis has to be addressed, as does diarrhea from Clostridium difficile or
Salmonella. In the case of recurrent genital herpes or herpes zoster the appropriate
maintenance antiherpetic antibiotic has to be taken in addition to the anti-AIDS
medicine. Side effects of treatment against AIDS: As
important as effective treatment of AIDS is, one cannot overlook the toxic effects
of some of the medications that are used to combat this disease. Doctors are always
aware of the importance of balancing the benefits of a therapeutic intervention
against the negative side effects of it. With AIDS treatment the relationship
between benefits and harmful side effects of the medications used to treat is
even more important as AIDS treatment can potentially span over several decades
and some side effects are quite significant. Also, resistant strains of AIDS are
always developing. Protease inhibitors, not long ago thought of as the cure-all
for AIDS, turn out to have significant drug side-effects of increasing fatty substances
(lipids) in the blood and causing diabetes mellitus. Fusion inhibitors cause damage
to body cells that contain large amounts of the energy packs, called mitochondria,
such as in liver cells and fat cells. The end result after 18 months of fusion
inhibitors is in many patients a starved look as the body fat simply melts away
through a process called fat dystrophy. The end results are higher risks of heart
attacks and strokes and the need for more medications to attempt to treat these
side effects with statins, lipid lowering agents and insulin for diabetes. Clearly,
this type of complex therapy is best done in close contact with a University Center
that specializes in AIDS treatment. Use this government
link for access to AIDS information and treatment centers (Ref.5).
Prevention
of AIDS The most important aspect of prevention is to avoid
unprotected sex between an HIV infected individual and an uninfected person. The
the use of condoms as a barrier method is of some help. Avoidance of anal intercourse
is also important because of what was discussed in the introduction to this chapter
on AIDS. The use of antiretroviral medications likely will reduce the risk of
transmitting HIV, but the proof for this is not yet in. A woman who is diagnosed
with AIDS when pregnant has to be treated with zidovudine. Without this the risk
of transmitting HIV to the fetus is about 40%, with zidovudine the risk of transmitting
HIV to the fetus is about 15% (Ref. 1, p. 1320, and Ref. 2, p. 5). | 
