THE CONCEPT OF THERAPEUTIC MANAGEMENT - E XEMPLARY IMPLEMENTATION OF ANTIRETROVIRAL TREATMENTS

Since the discover of AIDS in 1981 and the causal human immunodeficien cy virus in 1983, therapeutic strategies have gone through many phases . When the ACTG 175 and Delta trials demonstrated the clinical improve ment offered by regiments combining 2 nucleosides over monotherapy, co mbination therapy was being prescribed for less than 20% of all primar y infections. Less than one year later, this rate suddenly rose to 90% . At the same time, the clinical benefit in terms of reduced morbidity and mortality was demonstrated for triple therapy and by the end of 1 997, 65% of all treated HIV+ patients were taking the triple combinati on therapy, 34% were on bitherapy and only 1% on single drug regimens. This fantastically rapid evolution of management strategies appears e ven more exceptional when one realizes that these changes in prescript ion attitudes took place before expert groups were able to establish a ccepted guidelines. The number of patients under treatment also rose s harply from 57% in early 1994 to 87% in late 1997, while the number of active hospital files rose by 30%. These rapid changes in patient man agement schemes has had a major effect on HIV-related morbidity and mo rtality In 1997, the number of deaths fell by 41% and the number of ne w AIDS cases by nearly 50%. The number of hospitalizations has also de clined by 50% over the last 2 years. This is probably the first time i n the history in medicine that preliminary clinical studies have led t o direct patient benefit in so short a time. This achievement has been accomplished by the combined efforts of health care workers, patient associations, public authorities and the pharmaceutical industry. This global view must not however hide the fact that most all the prescrip tions used today are based on the results of clinical trials in a smal l number of patients over short study periods. Longterm efficacy and t olerance remain unknown. One must also keep in mind one other figure w hich has not varied over this period. The percentage of new AIDS cases in patients no ith no prior treatment because they are unaware of the infection or because they do not want treatment remains unchanged at 40%.