LivingSantiago Moreno:? Current medicines cannot cure AIDS

Santiago Moreno:? Current medicines cannot cure AIDS

After 20 years of knowledge of the virus … in what situation are we today to combat it?
-In terms of infection control, this is a time of stability. After the discovery of new drugs and new laboratory techniques that allowed us to better understand the virus, we experienced what scientists called a “honeymoon” with AIDS: a large decrease in mortality in Western countries and a tremendous improvement in the patient status. Today, progress in reducing the number of pills to take, increasing comfort, and reducing toxicity are still significant; but unfortunately there is no progress in eradicating the virus.

What do we understand by eradication of the virus?
-The possibility that a patient stops taking the medication forever. It is clear that today AIDS is no longer what it used to be, that a patient who goes to the doctor and is well treated no longer has to die from the disease, but that has a price to pay: difficult medication, toxic and complex.

So it’s a bittersweet feeling …
-More than anything it is a matter of putting your feet on the ground and realizing that, despite all that we have advanced, the disease is not cured yet.

Can we expect progress in the near future?
-With current medicines, as we know them today, I don’t think we can eliminate the AIDS virus. They are sure to greatly improve your efficacy, decrease your side effects, and lower your dosage demands, but they will not eradicate the disease.

What is necessary, then, for it?
-I believe that the line of research should focus on the search for mechanisms that make it possible for the virus, even if it does not disappear, to remain unexpressed forever.

How is that?
-You and I are surely infected by a virus from the herpes group. These organisms can live in a state of latency throughout the life of the individual who carries them. The virus will never be eradicated from the body, but it does not have to be harmful. I believe that the next step in the fight against AIDS has to be for some wise man to find, thanks to immunology, a mechanism to achieve that our body forms the type of defenses necessary to surround the virus inside the cell and not let it leave. At that time, patients can stop taking the medication.

Until that moment, what problems does the patient who has to be medicated face?
-The current medication is extraordinarily effective, but it raises three problems. The first is the difficulty of adherence.

What do doctors call adherence?
-To the correct follow-up of the medication. The pills can be very good, but if they are not taken as they should be done it is useless.

But that happens with all diseases …
-Yes, but unfortunately HIV medication has all the classic characteristics that impair adherence: there are many pills, several medications, you have to take them for life, with patients who in many cases are asymptomatic … You have all the ballots for the individual to discontinue their medication at any given time. The lack of adherence not only prevents healing, but also facilitates the resistance of the virus. And that is the second serious problem with today’s medication: the development of increasingly powerful resistance.

And the third problem you were talking about?
-It’s the toxicity. There are two major side effects. The first is lipodystrophy, a disorder in which the individual loses fat from some parts of the body, mainly the face, arms, buttocks and thighs. This problem affects 40 or 50 percent of patients after three or four years of medication. The second long-term toxic effect that worries us is that blood lipids, cholesterol, triglycerides are increased … And that is a cardiovascular risk factor.

Is today’s patient well informed of these risks?
-The AIDS patient is the most informed that exists on matters of medication. The way in which we have learned to treat these patients must be exported to other types of disease. With the HIV positive, adherence is vital, so the doctor spends a lot of effort to inform you about the medication you are going to take.

Why is adherence more important in HIV patients than in other patients?
-Because the disease is very demanding. To treat tuberculosis, for example, the affected person can lose 30 percent of the medication, and nothing happens. In the case of hypertension, up to 40% of the wrong medication can overcome the problem. But with HIV, more than 90 percent of the pills have to be taken well.

And is it done?
-After a year of treatment, only 50% of patients take more than 90% of the pills correctly.

What can be done to increase that percentage?
-In hospitals we have specific adherence consultations. In them, a psychologist or a nurse monitor the way in which the patient is complying with the medication. In addition, the doctor and the pharmacist participate in the control of these patients.

Is there a changing trend in terms of risk factors for the disease?
-Obviously, the transmission routes remain the same. But the pattern of the spread of the disease is changing. For example, the modification of drug use habits, by switching from injected to inhaled heroin, among other things, could serve to reduce the importance of the parenteral route as an extension mechanism. The importance of sexual health campaigns that promote safer behaviors when having sex is also appreciated. But history has thrown us some surprises. Children who were 4 or 5 years old when AIDS was at its worst, today are 20 and see the disease as “old-fashioned”, as something that affected other generations. They have embarked on risky behaviors at a time when AIDS no longer has such a social impact. As a result, the United States has shown, for example, an increase in the incidence among adolescent homosexuals, the number of sexual partners per person and the incidence of gonorrhea have increased, and the number of people using condoms has decreased.

Do you mean that we are facing the risk of a rebound in evil?
-We do not know. What is clear is that the decrease in social impact and the good news about the ability of drugs to stop the spread of the virus can have an effect on a relaxation of habits. A paradigmatic case is that of couples in which both members are positive. It often happens that they abandon the use of barrier measures in their sexual relations without realizing that an infected patient can be reinfected and impair the control of their disease.

In Spain the data is not very good …
-Because in Spain the main group of affected people have been drug addicts. The great mistake in the Spanish anti-AIDS policy was being too conservative when taking control measures among the addicted population. There was some qualm about starting programs such as the exchange of syringes, for example. And this problem has caused a chain reaction. In the United States, most of those affected are homosexuals. In Spain, the most affected population are addicts who, for the most part, are heterosexual, so our country also has a high percentage of infected women and children born with the disease.

Jorge Mayor

This interview was published in November 2003, in number 270 of VERY Interesting.

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