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What’s New in HIV?
by Deneen Robinson
The science of HIV has continued
to marvel us with an ever-changing landscape of new information
that keeps us guessing as to what is next. The truth is that
this virus will always challenge us. We will never be bored.
There will always be something new to learn or teach others.
We know that antiretroviral therapy is effective in treating
HIV disease. However, as people on HIV treatment age, their
options become more limited and the need to bring new drugs
to market is increasingly important. In addition, women’s
access to appropriate care, with specialists who not only
understand HIV, but healthcare for women is still an issue.
We need to continue to get women and people of color into
treatment and clinical trials, in roles other than victims.
New Treatments
The recently approved Lexiva,
T-20, Emtriva and Reyataz have given us a few more choices
for people who are treatment experienced. Unfortunately, because
of the timing of approval and the problem of HIV resistance,
there have not been enough drugs to give us a complete regimen
of at least three new drugs for treatment-experienced people.
As time goes on and people experience multiple resistance,
it is more and more difficult to find compounds that will
work. The pipeline offers promise for those people.
Tibotec-Virco, a Belgian
pharmaceutical company recently purchased by Johnson and Johnson,
has two remarkable drugs in development that are designed
to meet this need. TMC-114 is a second-generation protease
inhibitor designed to be active against protease resistant
mutations. In vitro data shows that TMC-114 has potent activity
against both wild type and resistant forms of HIV. The drug
has demonstrated greater efficacy if boosted with ritonavir.
Although the trials have been small (50 people), the results
look promising and have allowed the manufacturer to move to
the next stage of clinical development. TMC-125 is a non-nucleoside
reverse transcriptase inhibitor (NNRTI) also produced by Tibotec-Virco
that has demonstrated in vitro that it can work in
the presence of the K103N mutation. K103N is the mutation
that causes one to lose the entire class of NNRTIs. The future
of treating HIV disease depends on the creation of novel compounds
that are successful in the presence of multiple resistance.
Superinfection
At the 2003 International
AIDS Society (IAS) conference in Paris, superinfection was
discussed with clinical data to prove its existence. According
to additional information presented at IAS, we now have people
who have tested positive with no treatment options. This news
has a number of implications. Those who test positive with
no treatment options have to wait for new compounds in the
same way people were waiting for options in the early years
of AZT. It also means that the hope for a vaccine is even
more elusive due to the difficulty of creating a vaccine that
encompasses all the known mutations and the possible mutations
that may occur in the future. Finally, as the number of people
who have superinfection increases, mortality may increase
as well.
Women and HIV
There has been a great concern
about the number of women who are testing positive for HIV.
Interestingly, since the early 1980s, women have been present
among the numbers of people both living and dying from HIV
disease. The sudden fascination with women has yet to translate
to equal participation of women in clinical trials, expanded
access programs and access to care. In early 2003, Dr. Kathleen
Squires presented a paper on the relationship between HIV,
gender and treatment. Women are still the last to be treated
and the lowest number of participants in clinical trials.
Interestingly, she pointed out that women are as capable as
men in handling antiretroviral therapy.
For years women have been
saying that there are differences in how women respond to
antiretrovirals. In this document, Dr. Squires indicates that
women do experience greater side effects or more severe side
effects to some of the currently used antiretrovirals. In
order to minimize these problems women should be consistently
part of clinical trials. Also, the different side effects
that women are experiencing should be investigated and physicians
and other health care providers should be made aware of this
information. These differences should be implemented into
the care plans of women living with HIV. We should stop paying
lip service to these issues. If we truly want to do something,
we should consistently do the “extra” work required
to ensure the participation of women in all aspects of HIV
care.
It means ensuring that the
voices of women are heard even if they are not able to disclose
their status. It also means that we address the barriers to
health care by providing day care, food vouchers, bus tokens,
etc. Finally, it means listening to the issues that women
have raised and allowing the voice of women to be more than
the accepted few that we have been listening to up to this
point. It means ensuring that the voice of women continues
to grow until there is equal representation.
For those of us who have
always been the stakeholders, it means sharing your “territory”
with someone who has as much right to be at the table as you.
Most importantly, it means that stakeholders take the responsibility
of bringing someone else along, so that there is always a
voice at the table that reflects the unique needs of all populations
impacted by HIV.
African Americans and
HIV
In addition to the constant
hype about women, we are touting that African Americans are
the new “face” of HIV. It boggles the mind. African
Americans have always been disproportionately impacted by
HIV. Always. For those of us who have been around since the
epidemic began, we know what the myth has been. “HIV
is a gay, white male disease.” Instead of dispelling
that rumor, that myth has actually been the catalyst for much
of the denial that occurs in the African-American community
about their HIV risk. Unfortunately, it is very difficult
to fix something this huge. Now what has happened since we
have begun to talk about African Americans has been a decrease
in funding, waiting lists for AIDS Drug Assistance Programs,
flat funding of Ryan White and limited pharmaceutical dollars
for community organizations. On observation that does not
make sense. What are we doing to deal with the societal issues
that have caused this new incidence? What are we going to
do for the large number of people who are going to be accessing
care? More importantly, how are we going to pay for it?
The one thing that women
and African Americans have in common is limited resources
to pay for costly medical care and AIDS drugs. In light of
the large number of underpriveleged people accessing services
and society’s expressed concern for these groups, why
are we limiting money for services instead of increasing it?
It brings to mind the idea that now that the epidemic has
become more associated with poverty and other societal ills,
we are treating it just like we have consistently treated
the poor in this country. We treat them with disrespect. We
show our disrespect for this “new” group of infected
individuals by not ensuring that they are a part of the “cure.”
Going forward, why don’t we try to ensure that these
groups are included in trials and ensure that they have equal
access to medical care and treatment?
The saying goes, “The
more things change, the more they stay the same.” As
the arsenal of medications to treat HIV has grown, we are
still perplexed about finding new ways to treat HIV disease.
As the advancements in understanding this virus have grown,
we still have yet to discover an effective way to create a
vaccine. We have learned that HIV has a way of changing its
outer core to elude antibodies. We have learned that HIV replicates
at such a rapid rate that the body is always behind in trying
to kill the newly created virions.
We have a number of novel
ways of treating HIV in the pipeline. The success of creating
T-20 has opened the door for other entry inhibitors. There
are a number of different types of entry inhibitors that,
if successful, will give us more ways of suppressing this
virus. The reality of a cure is still far off. The more we
learn about HIV, the more the difficulty of finding a cure
seems. There are a number of companies manufacturing vaccine
options. Our greatest hope for a vaccine is a number of years
in the future. In the meantime, we are going to have to work
on ways to keep people healthy until the cure or better treatment
options are available.
The host
The host for HIV is very
complicated. Each of us is unique with our own problems and
clinical deficiencies. These differences make it difficult
for us to develop a simple formula of treating HIV disease.
Clinicians are learning that understanding the host is the
key to successfully treating HIV disease. As we pay attention
to host factors such as family disease histories, risk for
cardiovascular disease, cultural differences and gender differences,
we are better able to find the most appropriate treatment
for the person living with HIV. We have a number of trials
that are exploring host issues such as TDM—therapeutic
drug monitoring. The TDM trials are trying to see the impact
on viral suppression if we dose medications based on the unique
issues of the host. We’ll see what the results show.
Also as we learn more about HIV disease, we are including
host factors as ways to measure someone’s risk for hyperlipidemia
and high glucose in people living with HIV.
Perhaps the newest reality
is that the more we learn, the more we realize we need to
learn. The most important idea is that we need to be vigilant
in this fight. The future of treating HIV disease is for all
of us to continue to advocate for new treatments and better
care for those living with HIV.
Deneen Robinson is an African
American woman who has been working in the field of HIV education
for seven years. She has been living with HIV for 11 years.
She says that, “During this time, my ability to access
and understand information has been the most powerful tool
in my personal fight against HIV.” She is a resident
of Dallas, and a graduate of the African American AIDS Institute
in Los Angeles. Shortly after finishing work on the Drug Guide
project she accepted a position as Advocacy Relations Manager
with Abbott Laboratories.
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