Salvage Therapy for HIV-1 Infection - The Challenge Grows
[J Mellors, J Montanerl Lancet 2000;355:1435]

This is a brief review of the Third International Workshop on Salvage Therapy held in Chicago, April 12-14, 2000. The main story was that investigators continue to report high rates of treatment failure with "salvage regimens." Specifically, Moncroft of the Royal Free Center for HIV Medicine in London reported virologic failure rates in the Euro SIDA cohort of 50%, 70%, and 80% after first, second, and third courses of antiretroviral regimens. The summary stated that several trials showed that about 30% of patients with failure using PI-containing regimens responded to salvage treatment, and about 15% responded if the prior regimen contained an NNRTI. Robert Hogg from Vancouver provided yet another report indicating that experience of the provider was a strong indicator of better outcome for salvage regimens. Strategies to improve response include the avoidance of monotherapy, use of resistance testing, and promotion of favorable drug interactions, particularly the use of ritonavir with other PIs. The reviewers did not endorse the use of polypharmacy (mega-HAART) due to the lack of controlled trials and concern for toxicity. They also did not endorse "strategic treatment interruption" due to lack of controlled data and concerns for safety.

Comment: Nearly all studies since the inception of the HAART era in 1996 have shown that the best results are with the first regimen. There has been relatively little progress in defining methods to deal effectively with patients who have virologic failure except for resistance testing. The most recent CDC statistics on HIV-associated mortality are sobering in showing that the dramatic declines of 1996-1998 plateaued in 1999. JGB, 5/3/2000