by Howard Grossman, M.D.
Next year marks the 10-year anniversary of HAART (Highly Active Antiretroviral Therapy) for HIV. Great strides have been made since those early days of HIV treatment, when suppressing HIV came at a price that included multiple doses of many pills and serious side effects that could make treatment difficult to tolerate.
Treatment is better today. In the past year alone, six HIV drugs have been approved, including two new once-a-day combination tablets that contain two of the medications required for triple-drug therapy. Some of these new drugs have real advantages over older drugs, including fewer side effects, no food restrictions, infrequent drug resistance and the convenience of one pill once-a-day dosing. In fact, the new once-a-day combination pills mean that, for the first time, HIV therapy for some patients can be reduced to just two tablets taken once a day.
More treatment choice is great news for doctors and patients. I don't have a single patient who wouldn't rather swallow one or two pills instead of 20. More treatment options mean patients can better manage side effects as well by choosing drugs that can minimize anemia, high cholesterol or kidney problems based on their current health risks.
But are patients getting that choice? HIV treatment options are improving every year, but the habits and expectations of some doctors and patients seem to be stuck in the past. As a result, many people with HIV may be needlessly dealing with cumbersome dosing schedules for drugs that may cause serious side effects and may not even suppress the virus as effectively as others options.
Why do some doctors and patients prefer to stick with older HIV treatments, even as new alternatives appear? There are a lot of possible answers. First, although the FDA must find new drugs to be safe and effective before approving them, some doctors are concerned that newer drugs may be less reliable than their older counterparts. These doctors may prefer using familiar drugs and resist making changes when current treatment combinations work 'pretty well.'
Second, the most often-repeated mantra of many docs is 'if it's not broken, don't fix it.' This made sense when our only criterion for success was an undetectable viral load. When I look at my patients, however, and see elevated cholesterols and triglycerides, which may predispose patients to do an increased risk for cardiac disease, or severe changes in body shape and diabetes, it sure looks broken to me. Especially when those patients have other, easier options with fewer side effects.
As therapies improve, it's time to consider a higher standard for patients, one that involves more than doing 'pretty well.' In fact, it's time to reconsider a mindset in HIV treatment that says a patient regimen shouldn't be switched until it's completely failed.
Those ideas may have made sense 10 years ago, in the early days of combination therapy. Back then, patients and physicians were justifiably relieved to have new weapons to fight HIV. In those days, complex daily dosing regimens and serious side effects, from diarrhea to dramatic changes in body fat (also known as lipodystrophy) seemed unavoidable. With limited drug choices, it was simply the price to be paid for suppressing the virus.
Some patients still have little choice but to live with significant side effects—usually because they have a long HIV treatment history. But others may be living with problems like lipodystrophy, painful neuropathy or severe fatigue that are caused more by circumstance than medical necessity. For many patients, the improved treatments that are now available can offer more convenient dosing with fewer pills and even once-a-day dosing, reduced side effects or different risks, and a better profile on resistance, all possibly contributing to more effective suppression of HIV.
Of course switching therapies should never be done lightly, but proactively changing drugs to try to improve outcomes or quality of life is an important consideration, one that is more possible today than ever before.
If you haven't had a frank discussion with your doctor lately, it may be time to ask if the HIV medications you're taking are still your best options. If you haven't started HIV therapy because you're concerned about side effects, it's worth talking to your doctor about the newer drugs available.
Times are changing. Treatments are getting better. Make sure you're reaping those benefits.
Howard Grossman, M.D., a New York City physician in private practice, is Assistant Clinical Professor of Medicine at Columbia University's College of Physicians and Surgeons, and a member of the American Academy of HIV Medicine.
