a special program of the National Emergency Medicine Association (NEMA)

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Week: 606.7

Guests: Dr. David Hardy, Dir. Research, Pacific Oaks Med. Ctr. Assoc. Prof., UCLA School of Medicine, Los Angeles; ‘Anthony’ - HIV positive patient

Topic: Treatment regimen for AIDS patients

Host/Producer: Steve Girard

NEMA: The war against the HIV virus has been frenetic, and has recently produced some heady progress...and recent indications are that the virus...while not dying off completely, can be held at bay if patients use a strict regimen of drugs...taking them consistently to prevent the creation of resistant strains of the virus. Today we have Dr. David Hardy, research director at the Pacific Oaks Medical Center and an associate professor at UCLA...and we also have Anthony with us...who is an HIV patient waging his own personal fight against the condition. Anthony, what’s your view of the changing landscape of treatment....?

ANTHONY: Well, being HIV positive, I’ve seen a lot of changes...especially in the last two years...with the advancement in therapies and the new drugs from what was available, you know, five years ago. So, there’s been a lot that has happened, and it’s tremendous...the efforts that have gone on scientifically, I think, are great. It’s great for the patient.

NEMA: Dr. Hardy, tell me about your work in developing treatment programs for AIDS patients...

HARDY: I’ve been involved in HIV treatment and research since about 1983, and it’s been a struggle at times, it’s been a disappointment at times, it’s most recently been a real joy to see the successes that have been occurring in terms of being able to offer persons with HIV infection some very effective therapies...and I think that’s been a big change that we’ve seen over the last 3 or 4 years, which has been a remarkable improvement in the way people are living with HIV infection more than ever before. I think a very important testament to this has been the recent report this fall from the Centers for Disease Control, which for the first time in the history of HIV in the U.S. , noted a decline in the number of persons dying from AIDS between 1995 and 1996. And this occurred even before the very potent and powerful protease inhibitors made it onto the market in the United States. So I think we would anticipate that this decline in AIDS deaths was going to increase even more so over the next coming years. It’s great news to be able to see that we’ve made a dent, an important dent in improving life span, and hopefully lifestyle, with persons who are HIV positive.

NEMA: The most promising news I hear is that though the virus hides in certain parts of the body’s immune system...staying on a tight treatment regimen keeps the effects at bay without the body developing a resistance to the drugs. But the regimen itself is tough....

HARDY: I think one of the most interesting things here, the two sides of this coin are that, while we’ve seen some remarkable improvements in HIV therapy, in terms of the results that are occurring...being able to suppress the virus, improve the immune system, and really decrease the chance that someone’s going to have the complications...potentially a life-threatening complication from HIV infection. This has come because of the use of multiple medications. And what’s become obvious to many people, and Anthony can speak to this better than I can now, is the fact that needing to take somewhere between 15 and 20 pills per day can be a tough thing to do...and remembering to do that multiple times per day...to take it with or without food sometimes, take it with or without other medications at times, schedule it around a very busy day to begin with...is a real challenge. And what we are recognizing that, while the results are great, the long term durability or duration of these results is very much dependent on the patient being able to continue to take the medications regularly. And able to be adherent to a certain regimen. And that’s something that’s posed a new and exciting challenge to us...that we need to make these medications easier to take...so they don’t have to taken so many times per day, and that they can be taken with or without food, as opposed to one way or the other. And be taken with other medications...we need to simplify the regimen. And that’s something that we need to put more and more to all the time. ??? There was recently a new medication that was put on the market about six weeks ago called Combivir, which was an important first step in this direction, in that it was able to combine two commonly prescribed medications - AZT and 3TC - into one pill. And now, it enable patients who were taking as many as 6 pills per day to now only take 2 pills a day, because it’s decreased the pill count in that way. This is not the final word by any stretch of the imagination, the cure for AIDS...but it’s really going to make it easier for persons who are taking the two medications together...make it easier for them to take them on a regular basis.

NEMA: In treatment of many conditions or illnesses..patients can do well if they stay on the regimen of medications...but still they fail to do so. Anthony, how hard is it to stay on the regimen you’ve been prescribed for HIV?

ANTHONY: Well, when you’re on a three times a day regimen of taking medications, it’s a lot harder to remember....you’re trying to schedule, at least I’m scheduling 8 - 2 and 8...type of approach. You know, 8 in the morning, 2 in the afternoon, 8 p.m. But, depending on the pills you’re taking at the time...when are you having lunch? What time? You can take them an hour before you eat, or an hour after...or with food, whatever...can depend a lot on the course of your day. So, remembering that and trying to be compliant can be rough. Something...doing something on a twice a day basis is a lot easier...but then again, the psychological approach of that many pills in your hand that you have to put in your body, is...after a while, it gets to you. Just thinking about, "How much am I ingesting at one time here"? But the benefits and the effects of it are the important aspect, and every time I come see the doctor and find out that the results of my lab work are stable, or something like that, I know that the end result is I’m doing the right thing by being compliant.

NEMA: Dr. Hardy...how many...or what percentage of those prescribed this HIV fighting regimen fall off the treatment course?

HARDY: Well, I think it’s something that occurs over time. Many people, as Anthony just mentioned, start off doing very, very well...motivated by the fact that when they see the results of blood tests, they get encouraged. That what they’re doing is really paying off. When a patient comes back and sees that their viral load, for example, has dropped to a very low, and oftentimes an undetectable level...then that’s a great feeling. It makes you think, "Wow, it’s all been worth it"! And when the T cells start to rise, instead of fall, it feels great, because you can see the fruits of the labor. Being compliant with the regimen. I think the tough thing, and I think any of us can relate to this very easily, is that trying to remember to do the same thing every single day ....day in and day out, around a busy schedule, becomes very difficult. It becomes monotonous, too. I think it’s something that...any kind of long term treatment really makes it incumbent upon the health care system to make it a little easier...to be able to design a regimen of medications that can fold into what the person’s already doing: eating breakfast, eating lunch, eating dinner. And as Anthony has mentioned, taking medicine twice a day instead of three times a day, allows someone not to have to carry pills around with them during the course of the day...take them with their breakfast, with their dinner...or take them when they go home tonight, to bed. It makes a big difference, and I think that’s something that is going to be more and more important all the time, is designing treatment regimens that people can actually live with.

NEMA: What do you tell those patients who are doing well...and ask what they can do to stay on that plateau...and continue to stay strong?

HARDY: I’m going to let Anthony answer that as well, but briefly, what I’d say is that I think trying to reinforce the positive results that come from taking medications regularly, and helping patients understand that taking medications irregularly can lead to resistance. And resistance to the medications leads to them becoming ineffective. I think that’s the thing that needs to help people understand why it’s important to be compliant. And I’ll let Anthony talk to this issue as well...

ANTHONY: I think the biggest issue there is making sure that you do take the meds at the appropriate times in the doses, as well as the with food, without food regimen....according to the type of medication. But better than that, to keep stable on a good quality of life....and I think the other important aspects of that are good nutrition, good rest, and exercise...which are very important...at least that’s what I feel helps me.

NEMA: I guess that’s the importance of the term I’ve heard...."drug holidays"...I guess not taking those holidays is more important that ever...

HARDY: The term "drug holidays" basically came from the fact that we used to think that it was okay for people to stop taking their medications, just to kind of alter up their time, after taking the medications for a while. Give them a little respite from the intensity of taking medications multiple times a day. We’ve now learned that that kind of drug holiday can sometimes be detrimental, in that it can allow the virus to become resistant to the medications. What we strongly encourage people to do is, if they forget their medications when they travel, when they’re working, when they can’t get access to them readily...is to...better to stop all the medications for a period of time, until they can get the one or two they’ve run out of...because taking them piecemeal has a higher likelihood of causing resistance.

NEMA: What’s coming down the line in the method of treatment for HIV patients?

HARDY: What we’re looking at is not simply more potent medications, but medications that have both potency and easy adhereability. Medications that someone can take once a day...they can take with food or without food...with other medications at the same time, and most importantly, ones that have a limited number of side effects. So, we’re trying to refine our therapy for HIV now, realizing that it’s something that will need to be taken for a long time...in order to make this a long term, successful treatment.

NEMA: Anthony...as part of the patient population, and involved in the strict regimen designed to keep you healthy...what’s your outlook?

ANTHONY: Well, from everything that’s been happening in the last number of years, I seem to have a better outlook...from everything I’ve read, and discussions with my doctor in relationship to what is going on...the new drugs and combinations. There’s more available now than there ever was. And research is still continuing...so, it’s increased my outlook that sometime in the future, HIV will be considered a chronic, manageable illness...similar to diabetes or something...hopefully, someone will be able to say that down the road.

NEMA: Our thanks to Dr. David Hardy of the Pacific Oaks Medical Center, and Anthony, an HIV patient from Southern California.

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about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.



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