First Person

Great strides have been made since the early days of highly active antiretroviral therapy, when drug choices were limited and suppressing HIV came at a price that included multiple doses of many pills and serious side effects. Today, however, treatment is much better. Since March 2003 alone, six new anti-HIV drugs have been approved. More treatment options mean patients, based on their current health risks, can better manage side effects by choosing the drugs that can minimize anemia, high cholesterol, or kidney problems. But are patients getting that choice? Not always. The habits and expectations of some doctors and patients seem stuck in the past, and there are a lot of possible reasons why. First, some doctors may prefer using familiar drugs and resist making changes, especially when current treatment combinations work 'pretty well.' Second, the most often repeated mantra of many doctors is, If it's not broken, don't fix it. This made sense when our only criterion for success was achieving an undetectable viral load. But when I look at my patients and see elevated cholesterol and triglyceride levels'which boost cardiac disease risks'or severe changes in body shape and diabetes, that seems broken to me. As therapies improve, it is time to consider a higher standard for patients than 'pretty well.' In fact, it is time to reconsider the HIV treatment mind-set dictating that a patient regimen should not be switched until it is completely failed. Of course, switching therapies should never be done lightly, but proactively changing drugs to try to improve outcomes or quality of life is an important consideration, one that is more possible today than ever before. If you have not had a frank discussion with your doctor lately, it might be time to ask if the anti-HIV medications you are taking are still your best options. If you have not started antiretroviral therapy because you are concerned about side effects, it is worth talking to your doctor about the newer drugs available. Times are changing. Treatments are getting better. Make sure you are reaping those benefits. Grossman is an HIV specialist in practice in New York City and was appointed executive director of the American Academy of HIV Medicine in September.