The AIDS crisis is over? In case you missed the papers last week, here are some clippings you might find interesting: the new drugs are already failing half the people taking them. Nothing has changed, idiot. Someone ought to put a bullet in your head.
--HIV Positive Gay Man
Thanks for the clips. I do read the papers, so I caught the "New AIDS Drugs Fail Many" stories when they first came out. But I appreciate your taking the time to send them, to say nothing of the extra effort you went to composing a very thoughtful death threat.
Last week I devoted an entire column to the end of "the AIDS crisis" without dwelling on--without hardly mentioning--the new treatments. The new treatments are not the sole reason AIDS is no longer a "crisis." The crisis was a particular set of circumstances, and circumstances have changed. While the new treatments are one of the changes, they are not the only one. But let's look at these new treatments--protease inhibitors and triple-drug cocktails--in light of this study "demonstrating" that they're failing half of all people on them. Docs at the San Francisco General Hospital AIDS Clinic looked at 136 "real world" HIV patients, as opposed to HIV patients enrolled in clinical trials (where failure rates have been in the neighborhood of 10 to 20 percent). Of these 136 people, 47 percent "achieved durable suppression" of HIV, while 53 percent "had evidence of ongoing viral replication." Those failing the new drugs weren't dropping dead, but their viral loads--the amount of HIV in their blood--were rising. Now, if one merely glanced at the headlines, one could get the impression that the drugs are failing half of all those taking them. But as everyone working in AIDS insisted earlier this year--when the headlines were good--one needs to read more than just the headlines to get the full story. "The mainstream press is always going to go to one extreme or another," said Dr. David Spach, AIDS clinician and coeditor of The HIV Manual, a guide for clinicians working with people with AIDS. "Last year they said this was a cure, which was not correct. Likewise, to give the impression now that all the therapies are failing half the time, well, that's equally wrong."
Why is that? "Most of the people in the San Francisco study were heavily pretreated [with less sophisticated AIDS drugs], had advanced HIV disease, or were drawn from patient populations that have a lot of problems with adherence to the medication regimens." Since the introduction of these drugs, we have known that not taking them properly can result in failure, and that the sicker someone is the greater the chance the drugs won't help them. "So with this particular sample," Dr. Spach said, "these kind of success-failure rates should be expected."
Dr. Spach sees almost as many "real world" patients as the number tracked by the San Francisco study and oversees the treatment of hundreds more. How are his patients doing? "Extremely well. I have a handful of people who are not adhering to the medications, and they are not doing as well. But my success rates overall have continued to be as high as those in the clinical trials."
Not even Dr. Steven G. Deeks, author of the San Francisco study, attributes the results to the "failure" of the drugs. On the HIV Insite Web site (hivinsite.ucsf.edu), Dr. Deeks writes: "In an attempt to determine why some patients fail potent protease therapy, baseline characteristics of this group were analyzed. Adding only a protease inhibitor to a pre-existing nucleoside regimen was highly predictive of a poor outcome [the pretreated]. Initiating therapy with a low baseline CD4 T-cell count and/or high baseline viral was also predictive of drug failure [the very sick]. Finally, documentation in the medical records of difficulty adhering to medical regimens was also predictive of drug failure [folks not taking the drugs properly]."
As Jim Puzzanghera wrote in the Knight-Ridder newspapers (under the headline "AIDS Drugs Fail Many"), "The reasons for the failures stem not so much from the drugs as from the people taking them, according to the study" [italics mine]. You included this clip with your death threat--did you not read it? To test the failure rates of the drugs themselves, as opposed to the failure rates of the people taking them, you would probably have to factor out the group who could not "adhere" to the treatment.
The other two "failing" groups--the very sick and the "pretreated"--should not be factored out: the drugs are indeed failing them. But barring the emergence of new treatments that can help them, these two groups are going to be "factored out" eventually by AIDS--and that is tragic, and I pray new meds come along that can help them. But if we make sure that everyone who needs these drugs has access, there will be fewer people "too sick" to be helped or "pretreated" with other medications, and this lethal "factoring out" will ultimately result in there being fewer people "failed" by the drugs.
As for the failure of the cocktails to help those who have "difficulty adhering" to the regimen, all that proves is that the drugs don't work if you don't take them correctly. The same can be said of any drug or treatment: aspirin won't work if you don't take it; chemo won't work if you skip appointments. If working for people who don't take them correctly is the standard by which AIDS treatments are to be judged--a standard applied to the treatment of no other illness--then there will never be an AIDS treatment that can't be shown to fail at an alarming rate.
Protease inhibitors and drug cocktails are not aspirin, of course. Folks have to take handfuls of pills daily--some with food, some on empty stomachs. Messing up even once or twice can have serious consequences. The protease bar is set cruelly high. Personally, I can't keep track of my asthma inhaler, so I can't imagine what it must be like to juggle all those pills. If I had AIDS and was enrolled in the San Francisco study, I would be among the 53 percent. The drugs are too complicated, and we need simpler, easier-to-follow regimens.
And they are on the horizon. "Right now, these drugs are very complicated," said Dr. Spach. "But in two or three years, it will be a lot easier. AZT and 3TC," two cocktail drugs, "just came out in a combination pill. What used to be eight pills a day is down to one pill twice a day. And there are drugs being developed now that will be twice-a-day or once-a-day regimens--probably all the new drugs that come out in '98."
Finally, it is important to emphasize that these are new drugs. They may yet fail. People should not construe them as "permission" to get infected: the best clinical trials have failure rates of 10 percent (better to be uninfected than face those odds). But even if the drug cocktails ultimately fail, or drug-resistant strains of HIV emerge, the psychological importance of the "protease moment," as writer Eric Rofes calls it, cannot be overstated. We have now seen that HIV is not invincible, that science can attack the virus itself and not just play a losing game treating the infections that kill people with compromised immune systems. Are we so in love with death that we are incapable of seeing this moment--this protease moment--for what it is?
Send questions to Savage Love, Chicago Reader, 11 E. Illinois, Chicago 60611.