Will AIDS turn from a chronic disease to a fatal disease again??

Dr. Daniel Albirt, senior physician at the Neve Or Center, Kaplan Medical Center, the outgoing secretary of the Israeli Society for AIDS Medicine summarizes a perspective of over 30 years in dealing with the HIV virus

A little more than thirty years have passed since the outbreak of... "a new disease that attacks young, white homosexuals and is characterized by immunodeficiency" was first described. These patients fell ill and died from opportunistic diseases, i.e. infections and tumors that do not usually cause disease in a healthy person, and were observed until 1981 only in patients with congenital immunodeficiency or in patients whose immune system was compromised due to various treatments, such as, for example, chemotherapy treatments for cancer.
This phenomenon gave rise to the name of the new disease: "Acquired Immunodeficiency Syndrome" or AIDS (Acquired Immunodeficiency Syndrome). About three more years passed until in the United States, Prof. Robert Glo, and in France, Prof. Luc Montanier, discovered at the same time, each separately, that the generator of this new syndrome is a new virus - the HIV (Human Immunodeficiency Virus).

Since its discovery, HIV has become one of the most studied viruses ever! Today we know exactly the structure of the virus, its chromosomal sequence, its life cycle and its transmission methods. This advanced research resulted in the development of drugs that allow the virus to be controlled and suppressed (although not eliminated).

In the first years, there was no effective treatment against the AIDS virus, so at that time the disease was considered fatal and the patients were terminally ill with a prognosis of between 3-5 years until death. The revolution in the field of AIDS treatment actually came in 1996, when the concept of combined antiretroviral therapy was introduced - the "cocktail" (HAART - Highly Active Antiretroviral Therapy), a treatment consisting of three different drugs that work against the AIDS virus. As a "life-saving" treatment, the HAART treatment in the first years consisted of drugs with a severe side effect profile, uncomfortable to swallow due to their size or taste, which had to be taken on an almost inhuman schedule (up to 6 times a day, including in the middle of the night!), versus The second option, which was death in those years, the patient had to "accept the judgment" of the difficult and almost impossible treatment in those years.

From a terminal illness to a chronic illness

Over the years, many drugs have been developed to treat AIDS, where today there are more than 20 preparations for the treatment of AIDS patients. The preparations available today have been found to be potent, have a tolerable side effect profile and are taken once or twice a day.

The situation today is that a patient receiving drug treatment against the AIDS virus will most likely live a normal lifestyle, without significant side effects and with a life expectancy very close to the average among the general population. It can be said that today, in many cases, being an AIDS patient has become a chronic patient, requiring regular treatment and follow-up similar to other chronic diseases such as diabetes, blood pressure, etc.
This means that in recent years the focus in the treatment of the AIDS patient has shifted from "treating the disease" (providing life-saving drugs even at the cost of severely affecting the patient's quality of life) to "treating the patient" (providing potential drugs with a tolerable side effect profile while maintaining the patient's quality of life And not only in the status of his illness!). If so, an informed look at the treatment of AIDS patients shows that the situation is good, even excellent, but is the picture really all rosy?

The second half of the first decade in the XNUMXs was characterized in terms of the treatment of AIDS by the introduction of many drugs for the treatment of AIDS, drugs from different groups with proven potency and a good side effect profile, to a certain extent this can be called the "golden period" in the treatment of HIV due to the wealth and availability of such a large amount of medicines.

A state of therapeutic "wealth" has also brought with it a noticeable "dryness" in recent years in regards to the development of new drugs to treat HIV. It seems that the pharmaceutical companies have exhausted the potential of drug development in the field of AIDS and have now turned to other avenues (such as the development of drugs to treat viral infection type C, for example). It is clear that the anticipation of the introduction of cheap generic drugs in the field of AIDS contributed to a decrease in interest in the development of new drugs in the field of AIDS. This is most noticeable in the field of drugs against HIV from the group of protease inhibitors (PI-PROTEASE INHIBITORS), a central and potent group for which no new drugs in development are on the horizon at all.

The relationship between the existing arsenal of treatments and the length of the patient's life

The current situation forces the professionals involved in AIDS medicine to see the existing drug arsenal as a limited stock, which is not expected to be renewed or increased in the coming years. This situation stands out significantly when we remember, as detailed above, that the AIDS patients are expected to live chronically blue for many years with their life expectancy close to the average life expectancy. This means that an AIDS patient diagnosed today at the age of 30 is expected to live with the disease for 40-50 years! It is clear that this period of time may be shortened if, over the next few years, a drug is found that will cure AIDS patients, but unfortunately, even in the most optimistic forecasts, we are more than 20 years away from the breakthrough that will lead to the discovery of a drug that will cure AIDS patients, if at all.

The insight that today's AIDS patients are in fact chronic patients who are committed to a continuous and close medication journey for many years, allows the comparison between AIDS patients and patients with chronic diseases that require regular treatment such as diabetes and hypertension. The expectation is that, similar to other chronic diseases, even among AIDS patients, the patients will not persist in the drug treatment for many years due to compliance problems, side effects, psychological problems and more. In such a situation, the patients are expected to fail the treatment. It can already be seen, also in controlled studies, that after about 4 years 20%-30% of patients change the drug treatment they took in the first line to treatments in the second, third line, etc.

Faced with the situation described above, where the arsenal of drugs that exists today is actually the arsenal that is expected to accompany AIDS patients in the next 30 years, there are many factors that influence the combination of drugs that will be given to a particular patient. For example, guidelines for the treatment of AIDS patients published by various international organizations (such as the American AIDS organization IAS, or the DHHS organization) often base their recommendations, mainly on the potency of a new drug against an old drug, in controlled studies over a period of years Only a few, that is, with a treatment horizon of only 4-5 years. The guidelines in general preach a treatment "tailored to the patient's measurements", but in practice they push a very limited choice of treatment options as a preferred treatment, while the other treatments are positioned as an alternative to these treatments.

Looking at the "whole picture"
In the daily clinic, there is also a direct effect of the choice of treatment by doctors who tend to change existing and good treatments for new treatments that look promising and "tempting" to use, as well as by patients, AIDS patients, who pressure their doctors to change the treatment or to receive a treatment consisting of the newest drugs that the guideline leads them to He is "new is good". This phenomenon was found in a number of studies which showed that over 40% of the patients changed the medication prescribed to them in the first six months of treatment, when in most cases no medically justified reason was found for this change.

The situation that exists today requires the community of doctors treating AIDS patients to stop, "take a step back..." and from a broader view, with a better perspective and see "the whole picture!".

Seeing the "complete picture" allows the medical community that treats AIDS patients to look at the set of factors that contribute to the success of treatment for an AIDS patient, when the treatment horizon is decades ahead and not a limited number of years. When the therapist has the knowledge and understanding that we are facing a patient who is expected to live almost as long as a person who does not have AIDS, that we are treating a "patient" and not a "disease" and therefore not only the patient's life expectancy is taken into account, but also the quality of his life, that there is a need to choose the appropriate treatment for the patient Most of all - "tailoring treatment according to size" while taking into account the recommendations of the guidelines, but on the other hand while we remember that treatments that are offered as a treatment alternative in the guidelines may be the recommended treatments for the particular patient. When it is clear that the arsenal of drugs for the treatment of AIDS patients is limited and is not expected to increase significantly in the future, so when choosing the treatment, the correct utilization of drugs must be taken into account, while maintaining therapeutic options in the distant and distant future! (This is the difference between a chess player who anticipates one or two moves ahead versus the one who anticipates 10-20 moves ahead).

Only a correct view and understanding of the current situation will allow the doctor treating AIDS patients to correctly consider the choice of the right treatment. In fact, the goal of an AIDS patient is a whole, long and comfortable life, with minimal damage to the patient's lifestyle and quality of life, even after 20 and 30 years from the date of his diagnosis.