WASHINGTON (Reuters) - AIDS experts, admitting that current
drugs cannot ever cure HIV infection and that they can cause
severe side-effects, issued new guidelines on Monday that
advise doctors to wait a bit before treating patients. They
have abandoned the idea of hitting the virus quite so early and
hard -- unless the infection is caught within days -- and have
said it is better to hold back until the infection reaches a
"Although antiretroviral therapy has provided extraordinary
benefits to many patients, we know that we cannot eradicate HIV
infection with currently available medications," Dr. Anthony
Fauci, director of the National Institute of Allergy and
Infectious Diseases (NIAID), said in a statement.
"We also recognize that serious toxicities are associated with
the long-term use of antiretroviral drugs."
Fauci said in an interview last month that the panel that makes
the recommendations planned to be a bit more conservative. "Now
we are saying you might want to start treating at a little bit
lower CD4 count and a little higher viral load," he said,
referring to the state of the immune system and the amount of
virus spreading through the blood.
The new guidelines are available on the Internet at
http://www.hivatis.org. Cocktails of powerful drugs, sometimes
three, four, five and even more, can hold the virus at bay. But
doctors admit it is still difficult to decide which drugs to
give first and which combinations are best.
"The updated guidelines recognize that we do not yet have the
data we need to make definitive recommendations about the
optimal time to start treatment," said Dr. John Bartlett, chief
of infectious diseases at Johns Hopkins University in
Baltimore, who served on the panel.
Guidelines Recommend Protease Inhibitors
But the guidelines, issued by the U.S. Health and Human
Services Department (HHS) and the private non-profit Henry J.
Kaiser Family Foundation, do name some favored drugs.
"One of these is the recently approved protease inhibitor
Kaletra, which is a co-formulation of ritonavir (approved in
1996) and lopinavir," HHS said in a statement.
"The other new entry is the combination of ritonavir and
indinavir. These treatment options take advantage of the
ability of ritonavir to boost the levels of other protease
inhibitors, creating a potent anti-HIV combination." Kaletra is
made by Abbott Laboratories Inc. . Indinavir is made by Merck
and Co. under the brand name Crixivan.
The new guidelines update the section on side-effects.
"We are very concerned about a number of toxicities associated
with the long-term use of antiretroviral drugs," Fauci said.
"Particularly alarming is the alteration of fat metabolism that
can emerge during treatment. We are seeing an increasing number
of patients with dangerously high levels of cholesterol and
That risk, he said, is one reason to wait before starting
treatment until it is really necessary.
But Dr. Benjamin Young, an AIDS specialist at Rose Medical
Center and the University of Colorado in Denver, said it was
important not to scare patients away from taking drugs.
"The fact that the recommendations are extended to issues
related to long-term toxicity is accepting that ... we are
dealing with long-term survival, and blessed by the fact that
there are many antiretroviral drugs to choose from," Young said
in a telephone interview.
"I tell my patients, 'You are a 40-year-old man and I would
much rather have you die at age 65 of a heart attack than die
at age 45 of AIDS'."
David Crawley, pharmaceuticals analyst at Schroder Salomon
Smith Barney in London, said the new guidelines were unlikely
to have a dramatic impact on prescribing patterns as many U.S.
doctors had already altered their treatment patterns.
He said the new guidelines would not affect his forecasts for
either GlaxoSmithKline or Swiss-based Roche, two of the world's
leading producers of HIV drugs.