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HIV/AIDS Demographics Similar in Dauphin County, Pennsylvania USA
- Stefan P. Kruszewski (29 March 2005)
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Drug exhaustion of HIV treatment: are we the culprit?
- Carlo Torti, Eugenia Quiros-Roldan, Giuseppe Paraninfo, Salvatore Casari, Filippo Castelnuovo, Giampiero Carosi (6 June 2005)
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Stefan P. Kruszewski, Psychiatrist-addictionologist Harrisburg, Pennsylvania
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I read with interest the important study of Sabin et al regarding the increasing minority of individuals from six (6) Southeast England HIV treatment centres who may need newer antiretroviral treatment to offset exhaustion of existing treatment options. (1) I appreciate their fine work. From this side of the Atlantic, I also thought that it might be of interest to compare the demographics of their cohort with a much smaller, but growing population of identified HIV-infected individuals from Dauphin County, Pennsylvania, USA. My information comes from the US Bureau of Census and the HIV/AIDS Surveillance-Bureau of Epidemiology Data Support- Bureau of Health Statistics and Research, Pennsylvania Department of Health. Briefly, Dauphin County is in Southeast-Central Pennsylvania, an eastern US state adjacent and south of New York and approximately 2 hours by car north-northwest of the Washington, DC metroplex. The county is 525 square miles with an estimated 2003 population of 253,388 persons. The racial breakdown, according to the 2000 census, is 77.1% white/Caucasian, 16.9% black/Afro-American, 4.1% Hispanic and 2% Asian. Approximately 14.1% of the population is over the age of 65. The median yearly household income is approximately $ 41,000. Slightly less than 10% of the population lives below the ‘poverty line.’ From the HIV/AIDS Surveillance Bureau and the Pennsylvania Department of Health, there were 401 living AIDS cases identified in the county in 2003 of which 72% were male. (That number has steadily increased from a figure of 283 cases identified in 1998.) 47% of those cases were white, 41% were Afro-American and 12% were Hispanic. The identified modes of transmission were as follows: 39% were men having sex with men, 27% from IV drug use, 21% from heterosexual sex, 8% from men having sex with men who were also IV drug users and the remaining 4% from a coagulation disorder(1), undetermined/other(2) and pediatric(1). 73% of cases were first diagnosed when the individuals were between 30 and 49 years of age and another 17% in the age range from 20-29. The Dauphin County, Pennsylvania USA population of persons living with AIDS faces the same problems identified by Sabin et al. Newer drugs with lower toxicity and less cross resistance are likewise needed here. (1) Sabin, CA, et al. Treatment exhaustion of highly active antiretroviral therapy (HAART) among individuals infected with HIV in the United Kingdom: multicentre cohort study. BMJ 2005; 330:695 Competing interests: None declared |
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Carlo Torti, Assistant Professor of Infectious Diseases University of Brescia, 25132 Brescia, Italy, Eugenia Quiros-Roldan, Giuseppe Paraninfo, Salvatore Casari, Filippo Castelnuovo, Giampiero Carosi
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We have read with interest the article by Sabin C. et al.,[1] reporting the high percentage of patients having experienced all antiretroviral drug classes currently available. This evidence is particularly worrying and prompted us several considerations. Among 2,411 patients actively followed-up in our clinical setting, 1,975 (81.9%) have received more than 3 different antiretroviral drugs during their treatment history, with 1,268 (52.6%) having experienced all three antiretroviral drug classes (nucleoside or nucleotide reverse transcriptase inhibitors, non nucleoside reverse transcriptase inhibitors and protease inhibitors). However, it is somehow reassuring to see that percentage of patients whose HIV plasma viral load is undetectable is marginally decreasing across subsequent treatment lines (77.7% in those on first treatment line, 82.8% on second or third and, 69.3% on later than third). Firstly, this is perhaps due to the fact that many antiretroviral treatment switches are due to toxicity or poor drug tolerability, thus emerging HIV drug resistances (and class cross-resistances) are less than a problem in such circumstances. Secondly, characteristics of new drugs enriching the antiretroviral treatment armamentarium are very much improved with regard to better tolerability and toxicity profiles, simplicity of administration and favourable resistance profiles. Thirdly, our expertise in managing antiretroviral treatment has improved over time. Altogether, these characteristics allow us to prescribe rescue regimens which are both effective and sustainable by patients in terms of adherence. Indeed, percentages of undetectable viral loads have been growing over time at a population level (from 49.4% in the year 2001 to 74.5% in 2005 in our clinical setting). However, the evidence of many patients experiencing multiple antiretroviral drug classes is a clockwork bomb that will soon explode if management of antiretroviral treatment is not rational. Still, we do not know so much about sequencing of antiretroviral drugs (that is, what drugs are to be used in first treatment lines which leave other options available for subsequent use). In absence of clear data, as many drugs become available, clinicians may be tempted to incorporate them in clinical practice in a not rational way. Rather than acting “individually”, clinicians should pursue collaborative efforts performing large clinical trials to assess what is the best therapeutic itinerary. Unfortunately, as HIV drug resistances are able to be transmitted, a indiscriminate prescription of drugs could erode drug availability for patients, even before they are treated with antiretroviral drugs. Finally, another concern pertains to the use of antiretroviral drugs by expanded access programs for patients whose treatment options are severely limited. This is a very delicate setting of patients and availability of new drugs is always very welcome. However, if new compounds are used as unique active drugs, HIV resistance mutations are easy to emerge and one may risk to apply a functional suboptimal therapy leading to a one-by-one exhaustion of therapy options. For this reason, an FDA letter [2] has been released to pharmaceutical companies urging collaboration to allow testing of multiple investigational agents in one study. Unfortunately, this alert has not been put into place. It is our responsibility to use new drugs in a rational way, that is in the context of optimized regimens. [1] Sabin CA, Hill T, Lampe F, Matthias R, Bhagani S, Gilson R, Youle MS, et al. Treatment exhaustion of highly active antiretroviral therapy (HAART) among individuals infected with HIV in the United Kingdom: multicentre cohort study. [2] Guidance for industry: antiretroviral drugs using HIV RNA measurements - clinical considerations for accelerated and traditional approval. October 2002 available at: http://www.fda.gov/cder/guidance/guidance/html Competing interests: None declared |
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