Forget paris in the spring: July was le bon temps, as the International AIDS Society’s second get-together—which alternates annually with the group’s bigger, brassier world AIDS parley, set for Bangkok next year—drew 5,000 of HIV’s brightest bulbs to the City of Light. And from the many sessions on how (no longer whether) to get HIV meds to the developing world, to the daily demos by treatment activists to fatten up the Global AIDS Fund (see “World on a (Shoe)string,” ), the focus was truly universal. While IAS announced no earth-shattering breakthroughs, the take-home on treatment was notably hopeful: cleaner versions of current drugs; better understanding of how to use specific combos; and, above all, two new classes—entry and integrase inhibitors—set to revolutionize treatment, especially for folks running out of options.
PARIS SCOPE: 6 QUICK PICKS FROM IAS
Study Notes: Conference treatment highlights
Juggle Before Drug Failure
BUZZ: In the year-long SWATCH study, HIVers alternating twocombos every three months saw drugs fail less than those who switchedonly at viral rebound. Theory: Keep HIV guessing about how to mutate.
DISH: With time on the same meds cut by half, switchers’ side effects were expected to ease. They didn’t.
DIRT: One of the two combos was d4T/ddI/Sustiva—not a topchoice. Switchers quadrupled the punch of their PI/double-nuke(Viracept/Combivir) mix by adding Sustiva for the first week of eachcycle. Fishy, says Mike Saag, MD. Wait for SWATCH 2—a bigger, better,cleaner study.
Got Lipo? Switch Sooner Than Later
BUZZ: 100 HIVers who ditched nukes d4T or AZT for abacavir(Ziagen) while sticking to the rest of their combo could regain a thirdof limb fat they’d lost to severe lipoatrophy.
DISH: Scans showed fat gains just shy of three pounds (out of anoriginal seven-plus loss) on abacavir, but the naked eyes of doctorsand patients had a hard time spotting the difference. Sadly, earlyimprovement seemed to level or even fall off after the first year.
DIRT: “Clinical lipoatrophy, assessed subjectively, may takeyears to resolve,” says Australian lipo pro Andrew Carr, MD, “if itresolves at all.”
Are Drug Holidays Over?
BUZZ: Strategic treatment interruptions (STIs) struck out inrecent tests, failing to: 1. prod the immune system to fight HIV on itsown; 2. reduce drug side effects; 3. increase HAART potency. They alsoupped resistance risk: STI pros Bernard Hirschel (Switzerland) and MarkDybul (NIH) had to stop trials early due to high rates of Sustiva and3TC resistance.
DISH: Most of Hirschel’s HIVers were on a Swiss-cheese combo—ddI + d4T + saquinavir/ritonavir—not recommended!
DIRT: Both docs study on, using other combos. Dybul hangs hishopes on more “resistance-resistant” STI meds and schedules (no NNRTIsand no 3TC; less switching on and off).
Will Reyataz Really Love Your Lipids?
BUZZ: In a Bristol-Myers Squibb study, PI vets were as likelyto be undetectable on BMS’ new PI atazanavir (Reyataz)—boosted withritonavir (Norvir)—as on rival PI powerhouse Kaletra (lopinavir withbuilt-in ritonavir). True to Reyataz’s advance press, they also hadlower cholesterol and triglyceride levels.
DISH: Study subjects were suspiciously ideal: They had enoughmutations to be “highly treatment experienced” (BMS-speak), but a full90 percent were still sensitive to the drugs in their combo.
DIRT: Hey, what about true salvage cases? And as the lipids-lipolink grows increasingly complex, Reyataz’s “the power of PIs withoutthe look of lipo” promise may fade.
Weakling Solo Trizivir gets Trounced
BUZZ: Looking for a gentler alternative to PI-based firstcombos, a big 48-week AIDS Clinical Trials Group study (read: not bigPharma) pitted Trizivir against Trizivir/Sustiva and Combivir/Sustiva.Lone three-in-one Trizivir failed about twice as often as its rivals.
DISH: Whatever their viral load at the start, Trizivir-only folks experienced too-high rates of viral breakthrough in the study.
DIRT: Other data confirm these findings, so the new view is: Notriple-nuke mix should fly solo. AIDS Healthcare Foundation lobbied theFDA to pull Trizivir from the market, but others disagree: It’s still auseful option, especially with a fourth med (NNRTI or PI).
Hype: Resistant HIV Sweeps Europe!
BUZZ: 9.6 percent of 1,633 newly infected people from 17countries contracted resistant strains of the virus. Of the newbies: 69percent had HIV subtype B (most common in the U.S., too), and 7 percentwere resistant to nukes. Media reports blamed sloppy prevention andadherence, but what about ineffective combos that let HIV reproduce,mutate and develop resistance?
DISH: In 1998, Europe had a 14.5 percent rate of resistant HIVtransmission—so this 2003 “shocker” may surprise only those withMTV-sized memories. Shock or no, IAS is developing pre-treatmentresistance-testing guidelines.
DIRT: Resistance rates are higher in the U.S., says IAS prez Joep Lange, MD, because more HIVers here take HAART.
WORLD ON A SHOE(STRING)
While experts at IAS brainstormed how to dispense meds in poor nations,across Paris, at a G-8 summit, the European Union bickered over moneyfor the meds—specifically, how little it could give the Global AIDSFund and still save face. Activists demanded $200 mil—to match theU.S.’s pledge—but the EU coughed up only 92. Then protestors walked outof French prez Chirac’s speech at IAS, hollering, “Donors give pennieswhile millions die.”