PI Perspective #14

June 1994     View PDF

Early Intervention - 1994

Beginning with the 1993 International AIDS Conference in Berlin, many people and their physicians became confused about the value of early intervention against HIV disease. Most of the confusion stemmed from conflicting reports about the effectiveness of long-term use of AZT in healthy people with CD4+ counts below 500. While there are continuing debates about the validity and implication of recent studies, there is no reason for this debate to cause confusion over the value of early intervention. Early intervention has never meant just using a drug once CD4+ cell counts fall below some predetermined level. Thus, the value of early intervention does not hinge upon the long-term success or failure of any individual drug. Instead, the concept has always referred to a broad spectrum approach of personal responses to HIV infection, an approach which was as valid and helpful in 1984 as it is today. What has perhaps fallen since Berlin, and rightly so, is the notion that there is some simplistic “cookbook” medicine solution to dealing with HIV disease. There will be no “cookbook” solutions until a cure is found. For now, response to HIV disease must always combine a variety of behavioral and medical approaches.

The Early Intervention Model
The Project Inform early intervention model, published in various forms since 1987 is a true expression of a holistic approach to health. Some aspects are meant to apply beginning the first day a person learns he or she is HIV positive. Other aspects, such as an antiviral or opportunistic infection strategy, come into play at various stages of disease progression.

General Health Maintenance

• Diet, nutrition, exercise
• Sleep habits, a reasonable workload
• Reduced alcohol and recreational drugs
• Health promoting behaviors

Studies in recent years have emphasized the importance of nutrition and exercise as key steps in HIV disease. Alcohol and drug abuse at the very least have severe indirect affects because they counteract all the other steps in the model.

Supportive Therapy

• Psychological, emotional, spiritual
• Stress management
• Empowerment, activism
• Balancing medicines (e.g. antioxidants)
• Philosophy of health / wellness

No one is prepared through learning or experience to cope with a plague. No one is inherently equipped to casually accept a diagnosis of a life-threatening illness or to see that illness devastate our communities. We all need help. Some find that help in the form of psychological, emotional, or spiritual support. Most seek help in learning how to better manage the stress that is so much a part of HIV disease. Many find great strength and support through the empowerment of taking control of their own health and in taking action against the failure of government and institutions to effectively address the issue of AIDS. Such activism can take many forms, such as demonstrations in the street, volunteering at AIDS service organizations, or writing a check to support groups who take action. Even medicine has its “supportive” approaches, such as the use of antioxidant supplements and vitamins to help counteract some of the cellular damage done in HIV disease. Finally, many people find great comfort in exploring philosophies of medicine, such as Traditional Chinese Medicine or ayurvedic healing, or scientism. Such approaches give people a meaningful way of understanding what health is. Ideally, they complement, rather than conflict with each other. Each has something to offer and there is no one single right path for everyone. The greatest benefits come from choosing one’s own personal pathway, while respecting the pathways of others.

Antiviral Strategy

• The virus is active and replicating
• Viral load increases as disease progresses and has consequences
• The challenge: when , what, how

The rationale for using antiviral medications is as clear or clearer today than it has ever been. But making decisions about what to use and when to begin are sometimes difficult. For a few years, the official government recommendation suggested that the choice could be made solely on the basis of a CD4+ count under 500. While the interpretation of early intervention studies such as the Concorde and ACTG 019 remain debatable, most scientists are in agreement that simply putting everyone with fewer than 500 CD4+ cells on a single drug, for an indefinite period of time, is not a rational approach. People with such counts differ widely in their needs and status, as well as in their response to therapy. For some, a CD4+ count of 500 is maintained for many years. For them, the argument for intervening with a drug might be modest or weak, since disease progression is less rapid. For others, a count of 500 is a brief stopping point between 600 and 400 or 300. For them, the argument for intervention might be much stronger based on the evidence of decline. In this sense, the T-cell trajectory (stability, improvement or decline) is more meaningful than a simple cell count.

Other factors which might influence the decisions about when of whether to use of antiviral medications include mild clinical decline, such as unexplained weight loss or minor symptoms. For some people, understanding one’s own general experiences with drug therapy is important. If you generally tolerate drugs well or poorly, this might predict your response to antiviral medications as well, at least on a psychological basis. Personal philosophy likewise plays a role, as some people prefer to confront disease as early as possible, while others might prefer to wait. Project Inform’s philosophy is not so much to recommend any particular drug or starting time, but to encourage people to become educated about the choices, the issues, and the risks and benefits. This applies to decisions about when to begin using such drugs, when to switch, when to combine drugs, and perhaps when to give the body a rest.

Decisions about the use of antivirals will become easier over time as better and less toxic drugs become available, and as better diagnostic markers of disease progression are available to guide one’s choices.

Opportunistic Infection Strategy

• Compensate for failing immune response
• Goal: maximum prophylaxis with minimum number of drugs
• Ultimately limited by drug interaction, tolerance, and resistance

This part of the model only affects people who have suffered a significant degree of disease progression. The first risk of major opportunistic illness occurs, on average, when CD4+ counts fall below 200 (though there is some modest risk for people with minor symptoms and counts below 300). While it is critical to take action to prevent infections in this stage of progression, there are real limits to our ability to do so. The best approach is one which employs the fewest drugs to prevent the largest number of infections. See the Project Inform Guide to Opportunistic Infections for more information.

Immune System Strategy

• Logical approach, building on the apparent temporary success of the immune system in combating HIV
• Goal is to support or strengthen immunity rather than fight the virus directly
• But much easier said than done

Ideally, HIV disease would be completely controlled through the immune system. Unfortunately, we know that the immune response eventually fails in most people, so we know there are limits. Many approaches have been proposed for utilizing the immune system itself to combat HIV, ranging from therapeutic vaccines and cytokine therapy to magic immune-boosting potions in a bottle. One thing we know for sure is that the immune system is far more complex than anyone had imagined, so simplistic solutions, while common, are almost always misleading. While research pursues the best ways to strengthen or rebalance the immune response, everyone has the power to make the best of their immune response through simple interventions with nutritional support, exercise, and the avoidance of immune damaging chemicals, such as alcohol and recreational drugs.

Summary
Early intervention is as alive and important today as it ever was. If anything has changed, it is the over simplistic notion which some gave used to narrowly define early intervention as the use of a single drug. While drugs may indeed play a role in early intervention, they are only likely to help when used as part of a comprehensive life enhancing strategy, one which understands that the body is more than the sum of its parts.

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