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” below), 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 two combos every three months saw drugs fail less than those who switched only 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 top choice. Switchers quadrupled the punch of their PI/double-nuke (Viracept/Combivir) mix by adding Sustiva for the first week of each cycle. 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 third of limb fat they’d lost to severe lipoatrophy.
DISH: Scans showed fat gains just shy of three pounds (out of an original seven-plus loss) on abacavir, but the naked eyes of doctors and patients had a hard time spotting the difference. Sadly, early improvement seemed to level or even fall off after the first year.
DIRT: “Clinical lipoatrophy, assessed subjectively, may take years to resolve,” says Australian lipo pro Andrew Carr, MD, “if it resolves at all.”
Are Drug Holidays Over?
BUZZ: Strategic treatment interruptions (STIs) struck out in recent tests, failing to: 1. prod the immune system to fight HIV on its own; 2. reduce drug side effects; 3. increase HAART potency. They also upped resistance risk: STI pros Bernard Hirschel (Switzerland) and Mark Dybul (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 his hopes on more “resistance-resistant” STI meds and schedules (no NNRTIs and no 3TC; less switching on and off).
Will Reyataz Really Love Your Lipids?
BUZZ: In a Bristol-Myers Squibb study, PI vets were as likely to be undetectable on BMS’ new PI atazanavir (Reyataz)—boosted with ritonavir (Norvir)—as on rival PI powerhouse Kaletra (lopinavir with built-in ritonavir). True to Reyataz’s advance press, they also had lower cholesterol and triglyceride levels.
DISH: Study subjects were suspiciously ideal: They had enough mutations to be “highly treatment experienced” (BMS-speak), but a full 90 percent were still sensitive to the drugs in their combo.
DIRT: Hey, what about true salvage cases? And as the lipids-lipo link grows increasingly complex, Reyataz’s “the power of PIs without the look of lipo” promise may fade.
Weakling Solo Trizivir gets Trounced
BUZZ: Looking for a gentler alternative to PI-based first combos, a big 48-week AIDS Clinical Trials Group study (read: not big Pharma) 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 the FDA to pull Trizivir from the market, but others disagree: It’s still a useful 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 17 countries contracted resistant strains of the virus. Of the newbies: 69 percent had HIV subtype B (most common in the U.S., too), and 7 percent were resistant to nukes. Media reports blamed sloppy prevention and adherence, 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 HIV transmission—so this 2003 “shocker” may surprise only those with MTV-sized memories. Shock or no, IAS is developing pre-treatment resistance-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 money for the meds—specifically, how little it could give the Global AIDS Fund and still save face. Activists demanded $200 mil—to match the U.S.’s pledge—but the EU coughed up only 92. Then protestors walked out of French prez Chirac’s speech at IAS, hollering, “Donors give pennies while millions die.”