The Treatment Revolution Has Arrived

Every few years a new drug or class of medications arrives on the HIV treatment scene that promises to revolutionize our long-term management of HIV infection. In 1987, AZT was hailed as the first antiretroviral drug to specifically inhibit HIV's reproduction. Unfortunately, as a single drug, it was doomed to failure. Who could have envisioned the rapidity (and it truly is, in the medical sense) with which scientists would rise to the challenge of a new, highly stigmatized, and inevitably fatal sexually transmitted viral disease and, within 15 years, have numerous viable treatments available? Medical research has endowed us with a plethora of potent and increasingly more tolerable treatments to render HIV infection truly a chronic manageable illness. Today, a mere three pills taken at bedtime can reliably and safely keep people's viral loads undetectable for years. All of our successes, however, have not come without a high price tag. I've participated in many a pharmaceutical industry'sponsored 'think tank' session to help the drugmakers design a better HIV trap. We've asked their best scientists to concoct simple, once-daily, nontoxic, and affordable medications with very few pills to swallow and which, if they failed, would leave other treatment options open'a tall order to say the least. Much as criticizing pharmaceutical manufacturers has become a beloved sport of patients, doctors, and other HIV treatment advocates, the industry finally seems to be listening. We have an ever-lengthening list of once-daily, reasonably nontoxic drugs at our disposal'for example, tenofovir (Viread), efavirenz (Sustiva), lamivudine (Epivir), emtricitabine (Emtriva), and didanosine (Videx EC). However, there were no once-daily options for people who needed to take a protease inhibitor'until now. The Food and Drug Administration has approved a revolutionary new protease inhibitor: atazanavir (Reyataz). As if optimally designed by the treatment committee, it offers most of the items on the think tank's wish list. Reyataz ' is as powerful and effective as any other 'gold standard' HIV treatment; ' is dosed only once daily; ' can and should be taken with food; ' does not increase cholesterol or triglyceride levels; ' has no effect on blood sugar levels; ' has minimal diarrhea or other general intestinal side effects associated with it; ' has no adverse effect on energy, mood, dreams, or sleep; ' selects for a unique 'signature' resistance mutation that preserves and (believe it or not) enhances future treatment options if a patient becomes resistant to it; and ' is priced competitively when compared with other HIV medications. Like all drugs, Reyataz has a few shortcomings. It can increase the liver enzyme bilirubin in your bloodstream, but fortunately it does so without damaging your liver. Reyataz can interact unfavorably with non-HIV drugs like Halcion, Viagra, Mevacor, Zocor, the Prevacid-type heartburn drugs, and the herbal antidepressant Saint-John's-wort. It can cause minor electrical conduction slowing on an electrocardiogram. And finally, Reyataz's levels in your bloodstream can be affected by other anti-HIV medications like Viread, Videx, Sustiva, and Norvir, so your doctor may have to adjust doses of Reyataz and these other medications when they are administered together. (To overcome some of these drug-to-drug interactions, many doctors plan to dose Reyataz at 300 milligrams per day with a single 100 milligram pill of Norvir.) Despite these cautionary issues, Reyataz will likely become the dominant player in the protease inhibitor class for years to come. Cohan is an attending physician and vice president with Pacific Oaks Medical Group, one of the nation's largest practices devoted to HIV care, located in Beverly Hills, Calif. He serves on the board of AIDS Project Los Angeles and has expertise in nutrition, anabolics, and exercise.