HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

April 23rd, 2008

Antiretrovirals in the Pipeline: And Then There Were … None?

The flurry of drug approvals that began in 2005 with tipranavir – followed rapidly by darunavir, maraviroc, raltegravir, and most recently etravirine – has been nothing short of astounding. Every experienced HIV clinician now has many patients who are on successful (read: suppressive) treatment for the first time ever. The Vancouver HIV program — wonderfully called “Centre for Excellence” (why couldn’t our clinic have chosen that name?) — reports that the incidence of drug resistance is declining “drastically.” And their experience is not unique, even though their “excellence” moniker might be.

All good news, right? Well, mostly.

The only downside to all this successful treatment is that the incentive for new drug development must be at an all-time low, especially for antiretrovirals with activity against highly resistant viruses. Unless there’s something flying below the radar, I can’t think of a single new drug likely to gain FDA approval in the next 2-3 years that will provide an effective option to people with no options – in other words, for those unlucky few who don’t have at least two fully active drugs available even with today’s extensive choices.

But how many patients are in this category? I suspect it’s not many: a highly unscientific survey identified three — yes, three — such individuals among the 1200 or so cared for in our clinics. The pie chart of virologic outcomes for people being treated for HIV now looks like this: undetectable virus (largest piece), detectable virus but patient not taking meds for any number of reasons (2nd largest piece), and finally, detectable virus, compliant patient, but no treatment options (just a sliver).

So how many patients with “no options” do you care for? What do you do for them and tell them?

Categories: Health Care, HIV, Infectious Diseases, Patient Care
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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Associate Editor

NEJM Clinician

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