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Being Alive
MEDICAL UPDATE: Three Major Questions And Some Possible Answers
Mark Katz MD and reported by Jim Stoecker
October 5, 1992
Being Alive 1992 Oct 5: 1

HIV care providers have been trying to answer three major questions. Some of the studies presented at the Amsterdam Conference have provided some answers.

The first major question is: does earlier intervention with antivirals really work? An Australian study looked at 994 HIV+ people in the 400-800 T-cell range. Half of the study group took 1000 mg of AZT a day (higher than the American standard of 400-600 mg daily). The other half took no antivirals. The groups were then followed for 93 weeks. The Australian researchers reported a statistically significant slowdown in disease progression among those on AZT and a significantly slower drop to a T-cell count below 350.

A similar study here in the US should be completed early in 1993. There appears to be mounting evidence that early intervention with antivirals does slow down progression to AIDS. Is there now enough evidence to make early intervention the standard of care? Each provider needs to give this question serious thought.

A second major question that we have been asking for some time is: are two drugs more effective than one? All studies of combination antiviral therapy that have so far been presented show that two drugs are generally tolerated well and exhibit little development of viral resistance. Combination studies generally report a correlation with higher, more sustained rise in CD4 than found with only one drug.

What we still do not know for certain is whether this CD4 rise translates to longer survival. And there is still the open question of when is the optimal point to begin combination therapy. When in the course of HIV disease do two drugs become better than one? The third major question that providers have been asking is: for people with low T-cells, does aggressive prophylaxis against opportunistic infections make a difference in survival? One study presented in Amsterdam reported on a prophylaxis regimen for five major OIs. The physician who developed the regimen followed a small group on prophylaxis for ten months and another similar sized group who did not comply with the regimen. What he found was that there were no deaths among those on the prophylaxis regimen and only four cases of PCP. In the control group, however, there were five deaths and seventeen cases of various opportunistic infections. This study was not scientifically controlled enough to be in any way definitive, and only a small number were involved. Nonetheless, the results are intriguing and further, better developed studies on this important issue are needed.