Wednesday, May 03, 2006

Salvage Therapy

In a story at the Wall Street Journal website, which is giving 10 free days of access, there is a story about "salvage therapy," which is what doctors resort to when an AIDS patient has become "immune" to all AIDS drugs. (Or, more specifically, when HIV has become immune to all current AIDS drugs.)

Steve Kovacev, a sinewy 52-year-old from Truro, Mass., has run the Boston Marathon and sailed in the Transpacific Yacht Race from Los Angeles to Honolulu. Neither event comes close to his current competition: a race for his life.

Mr. Kovacev has AIDS. He has used all the drugs available to fight HIV, the virus that causes the disease, but now almost all regimens have lost strength, and his virus is on the upswing. His plight places him in an unenviable class: the estimated 40,000 U.S. AIDS patients whose illness isn't responding to treatment. As a last-ditch effort, some of these people -- Mr. Kovacev included -- are turning to a regimen known among AIDS patients and doctors as salvage therapy.

In general, salvage therapy refers to any treatment devised by a doctor to save a patient when all other options have failed. There isn't a single recipe for salvage. Some AIDS physicians return to older drugs to wring out a last drop of efficacy, while others bid for access to experimental agents in a desperate attempt to bring the spiraling virus under control.

Today there are about one million people living with HIV in the U.S., with about 40,000 new infections a year. In 2004, the most recent year for which statistics are available, 15,798 people died from AIDS, down sharply, thanks to new AIDS drugs, from 51,000 in 1995. Hepatitis and drug toxicity contribute to deaths among HIV patients. Because of salvage therapy, most patients with drug-resistant virus are, for now, hanging on.

Even with optimal treatment, Daniel Kuritzkes, associate professor of medicine at Harvard Medical School, says, "we've only changed the slope of the disease progression, not halted it altogether, and eventually they do run out of options."

It's that last paragraph that I hate. Eventually, he says, everyone will run out of options, and the virus, so vicious in its ability to mutate, will become immune to all the meds. That's why I get monitored so often. Blood tests every month. Mountains of pills taken on a very strict timing regimen.

The article goes on to state that much of the problem of why the drugs fail is that many patients swap to new drugs as soon as new ones hit the market. So, the virus evolves until there are no more options. I've not changed drugs much. I'm still on one, 3TC, that I've been on almost from the very beginning. So, my practice is to stay on what works until it stops working.

And, so far, so good.


Anonymous said...

I hope it keeps on working for a long, long time.

Question : The people 'in need of treatment' ... what are the reasons they are not being treated? Financial?

Anonymous said...

I have one friend that takes vacations from therapy. It's an alternative that gives each cocktail a chance to last longer.

Anonymous said...

It is not really clear if "vacations" or inerupted or intermittent therapy truly gives each (or any) combination a chance to last longer. If the virus does not replicate it can't mutate and evolve. Any time it replicates, it mutates, and has a chance of acquiring a drug resistance mutation.

Interuptions in therapy do work for some percentage of people, but they may not work for others. It is best for each person to make decisions based on their own situation. Is viral load undetectable, is CD4+ T-cell cound stable, are there any side effects of drugs, etc... Length and timing of "vacations" is another factor to consider.

Steve Schalchlin said...

The issue of medical vacations is one that is still being debated, as "anonymous" stated. I know that Shawn Decker has tried going one month on and one month off because of how badly he reacts physically to the meds.

Anonymous said...

Med vacations are a touchy subject. The big problem for me is that because the drugs are still in their infancy (and they are) the medical community is still figuring out how they work and what the long term effects will be. If we don't stay on the meds constantly, then the next generation still has no answers.

I remember the side effects. I still have them, though not near as severe. It can be debilitating. I don't mean to put down other HIV Positive people and their life choices, but I feel there's a bit of responsibility here.

Brian FInch said...

The term here, at least in Canada, is one we are trying to get away from. The notion of salvage therapy has been used to keep people off new more expensive drugs that may be better for a patient, let's say with an extremely high lipid count. I'm thinking of Reyataz here and tenofovir. These two are with fewer side effects, and in the end cost the health care system less, but are restricted to "salvage" only.

That's not to say that switching all the time when something new comes on the market either. It takes a while for many to find a combo that is working with manageable side effects.

I think all the bareback sex, drugs, and non-compliance has lead to a lot of resistance -- hello, that would be me!

I am about to embark on a new tri-therapy, one is still yet to be determined pending geno and phenotype test.

I also read an article on how guys in LA are buying tenofovir along with their party drugs so that they don't seroconvert during the bare fuck sessions on crystal I guess.

I react so badly to retonivir, which is used with all the PIs to boost them, that I had to go on a suboptimal treatment where I discovered I was one of these "disconnect" guys. Disconnect is when you take suboptimal treatment but still react well to it. I did not achieve the undectable, for for two years I kept it down to aobut 5 - 6 thousand.

There is no doubt about it, meds can be a bitch.
I wonder if doing such things would have a negative affect in terms of resistance?

Anonymous said...


This is a difficult subject. I've been very fortunate in that I've been on the same combo for about 6+ years, and it's still VERY effective, and I have very few, if any, side effects.

As far as vacations go, once in a great while I have gone off the meds for a couple of days, and then back on them.

Years ago, I tried going off all meds for a couple of months to see if maybe I would be like that guy in Germany who seemed to be suppressing the virus after coming off the meds. I wasn't so lucky. The t-cells went down and the viral load went up fairly quickly.


Steve Schalchlin said...

Travis, I'm glad your meds are still working. You're one of my favorite pals and I want you here for a LONG time.