Salvage therapy for HIV infection: when and how

Virus maturation as a new HIV-1 therapeutic target

Development of novel therapeutic targets against HIV-1 is a high research priority owing to the serious clinical consequences associated with acquisition of resistance to current antiretroviral drugs. The HIV-1 structural protein Gag represents a potential new therapeutic target as it plays a central role in virus particle production yet is not targeted by any of the antiretroviral drugs approved at present. The Gag polyprotein precursor multimerizes to form immature particles that bud from the infected cell. Concomitant with virus release, the Gag precursor undergoes proteolytic processing by the viral protease to generate the mature Gag proteins, which include capsid (CA). Once liberated from the Gag polyprotein precursor, CA molecules interact to reassemble into a condensed conical core, which organizes the viral RNA genome and several viral proteins to facilitate virus replication in the next round of infection. Correct Gag proteolytic processing and core assembly are therefore essential for virus infectivity. In this review, we discuss new strategies to inhibit maturation by targeting proteolytic cleavage sites in Gag or CA-CA interactions required for core formation. The identification and development of lead maturation inhibitors are highlighted.

Psychosocial issues influencing treatment adherence in patients on multidrug rescue therapy: perspectives from patients and their health care providers

Multi-drug rescue therapy (MDRT) is often used for the treatment of highly experienced patients who harbor HIV variants with decreased susceptibility to multiple antiretrovirals. Patients on MDRT typically have limited treatment options, and without treatment, their prognosis can be poor. Yet the decision to go on MDRT is not always straightforward as MDRT can be associated with significant challenges including multiple daily doses, higher pill burden, emerging toxicities, and drug interactions. All of these may compromise adherence, which is often a major reason why patients may need MDRT in the first place. Little is known about how patients and health care providers (HCPs) experience MDRT. This study sought to explore areas of convergence and divergence between patients and HCPs in order to identify gaps in treatment and factors that may impact adherence to MDRT. A qualitative interview method based on grounded theory was used. Twelve patients and seven HCPs completed a 60-minute semistructured interview. Patients were asked about challenges, facilitative aspects of staying on MDRT, the decision to initiate treatment, their role, and the role of HCPs in their health care. HCPs were asked about their experience working with MDRT patients, their role, and the role of the patient. Congruent themes emerged from the two groups: developing a working relationship, treatment factors, information requirements, and readiness for treatment. There were no discrepancies in role perspectives. Patients and HCPs agreed on the need to optimize patients' readiness, willingness, and ability to embark on MDRT to maximize adherence. HCPs assumptions about beginning MDRT based solely on medical indications must be checked and discussed to ensure patients' motivation. In conclusion, adherence to MDRT demands a substantial behavior change, recognized as a major challenge by patients. Allocating the time to make a commitment to treatment can optimize adherence. It is therefore crucial that patients be provided with time to make informed decisions, explore and resolve their willingness and readiness to commit to treatment, and maintain supportive relationships with their HCPs, all of which can optimize adherence to MDRT.

The feasibility of a community-based directly administered antiretroviral therapy program

Improved treatment-adherence support programs are needed to help human immunodeficiency virus (HIV)-infected persons comply with complex highly active antiretroviral treatment (HAART) regimens. In an experimental directly administered antiretroviral therapy (DAART) program, treatment-naive and treatment-experienced persons who experienced failure of no more than 1 prior regimen were recruited from 3 public HIV/AIDS clinics in Los Angeles County. For 6 months, trained community workers observed ingestion of 1 of 2 daily HAART doses, 5 days per week, and questioned the patient about the second dose, which enabled intense adherence monitoring and real-time intervention. From November 2001 through November 2003, there were 67 DAART patients enrolled (69% Latino, 21% African American, and 9% white; 63% with annual income of <10,000 dollars). Preliminary findings show that a DAART program based in 3 public HIV/AIDS clinics was feasible in a low-income urban population. Effective communication between the DAART staff, the medical providers, and the pharmacy is essential for the successful implementation of this program.