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PD Dr. med. Christoph Boesecke Alternative HIV therapy with syringes
In the treatment of HIV, the approaches have changed again and again over the years. There is currently a lot of talk about dual HIV therapy or 2DRs (2DRugs). This means that instead of the previous three different active ingredients, there should only be two. What does this mean for the affected patients? What are the advantages? Are there any disadvantages? SCHWULISSIMO spoke about it PD Dr. med. Christoph Boesecke. He is as OberaDoctor in infectious diseases and immunology at the Medical Clinic I of the University Hospital Bonn. His main research interests include comorbidities and co-infections in HIV with a focus on acute hepatitis C. He is also a member of the board of directors of German AIDS Society and also a member of the Governing Board of the European AIDS Society “European AIDS Society” (EACS for short).
For a long time there was only one active ingredient against HIV, to which the virus became resistant within a few weeks, i.e. the viruses multiplied despite regular medication intake. With the switch to two active ingredients, it took longer for HIV to become resistant. The breakthrough came through the combination of three substances. A standard regimen now consists of two active ingredients from the class of NRTIs (also called nukes) plus a third active ingredient from the class of integrase inhibitors, protease inhibitors or NNRTIs. This principle works well. So why should one suddenly change proven therapies?
The breakthrough came in 1996 when there were protease inhibitors which, together with two NRTIs, finally made the therapy significantly more effective. In the meantime, however, there are so many different, highly effective single drugs that the idea is actually that with more modern therapy you only need two drugs to achieve adequate virus control. This is particularly the case with HIV-positive people who are already on therapy and "only" need maintenance therapy, so to speak, since they are very often already below the detection limit. The underlying idea is that the fewer drugs or active ingredients that have to be taken, the higher the chance that possible side effects can be minimized. However, it must be said that the triple combination therapies currently in use have very few side effects. In particular, nowadays there are really very well-tolerated substances with the second-generation integrase inhibitors.
What standards can doctors apply nowadays to find the right regime (editor's note: A regime is understood here to be the combination of different active ingredients for treating a disease - regardless of how many tablets are used) to find for the patient?
Basically, every HIV therapy should be individually tailored to the HIV-positive. This is best found out in a joint conversation with the HIV practitioner (e.g. work routine, family circumstances, concomitant illnesses, etc.). If you have been in HIV therapy for a long time, some HIV-positive people can certainly get one set a certain "tablet fatigue". For example, that patients say they can no longer see the tablets or that they become sloppy when taking them. Therapy with injections can of course be an alternative here. Small disadvantage: This therapy then has to be injected every eight weeks, which means that the patients then have to come to their doctor more often and of course have to be very disciplined here, as regularity is very important in order to develop resistance Avoid underdosing.
How is it taken into account that the patient finds the therapy that is tailored to their everyday life?
In the past it was often the case that you had known your patients for many years, so you also knew a lot about work, hobbies, pets, friends, family and other things. Nowadays it is often the case that you have known the patients much shorter, as we now treat every newly diagnosed HIV infection promptly. First of all, it is important to see what kind of person it is. So what does he / she do for a living, what is the private situation like. Does someone live alone or maybe in a shared apartment. So are the HIV drugs potentially visible to many or not? With the stigma, an aspect that should not be neglected comes into play. The latter is a big problem, especially for refugees in mass accommodation. All of this has to be worked out together within a short period of time. Even if HIV therapy is often not an emergency, patients want to start therapy relatively soon.
While one could get the impression earlier that certain HIV regimens are rather fragile, modern therapies seem to be rather robust. Are the new approaches “only” about effectiveness and safety?
No of course not. It is now standard that so-called "patient-related outcomes" always play a major role in studies. "Satisfaction questionnaires" are now always incorporated into the studies in order to include not only the data on the effectiveness and safety of the therapies but also the experiences of the study participants.
Many are certainly also afraid of the emergence of resistances. With increasing age, there can also be other diseases to be treated. What can the practitioner and patient do in such cases to avoid them?
In fact, with HIV patients who are fortunately aging significantly, the HIV consultation hour is primarily concerned with any new diseases such as diabetes, heart disease or high blood pressure. Here you have to take a closer look at how the various drugs can be reconciled with HIV therapy without interactions occurring and resistances arising from drug levels that are then too low in the blood. Therefore, it is better to briefly call the HIV practitioner when a new medication has been prescribed.
When it comes to technology, you always want to be “up to date”, be it with the latest cell phone or other technical gadgets. But why do many patients still find it difficult to get involved in new things? And above all, how does the patient know whether his therapy, which is actually going well, could not go even better with a more modern regimen and whether it would be time to change or whether he should stick to the one that has proven to be successful for him?
In the meantime, we have several "one-pill therapies" in HIV therapy, which means that the different active ingredients are combined in one pill. With these therapies, there are rarely moments in everyday clinical practice when patients want or have to be switched because of serious side effects. The use of dual therapies either as tablets or as injections can then be considered. However, there is no rule of thumb for this; this should also be weighed up in a one-on-one conversation between the patient and the practitioner.
Who is the new dual therapy for? Isn't it automatically suitable for all patients?
There are a few exceptions in which dual therapy using tablets or syringes should not be given: If resistance to the active ingredients to be used is known or must be suspected, if chronic hepatitis B is also present and also if someone has to take blood thinners because, for example, had a heart attack. Then the syringes are generally rather bad. However, this is less due to the therapy itself than to the increased tendency to bleed when the medication has to be injected into the muscles.
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