Perspectives in drug therapy of HIV infection

Current key issues in the drug therapy of HIV infection include the timing of treatment initiation, the use of multiple-drug therapy and the duration of treatment. Although most clinicians agree that symptomatic HIV disease should be treated, there is no consensus as to whether patients should be treated before symptoms develop; the results of the Concorde trial failed to demonstrate any long term improvement in disease progression or survival when antiretroviral therapy was initiated in asymptomatic individuals rather than deferring it until the development of AIDS or ARC. However, combination therapy may prove to be the most effective long term option. In the future, monitoring viral load or viral resistance may be a useful aid in determining whether antiretroviral therapy should be stopped or changed, particularly if any clinical benefits are transient or if adverse effects persist. New antiretroviral therapies must be evaluated in terms of both risks (associated adverse effects) and benefits (increase in survival, delay in disease progression or improvement in quality of life). There is an urgent need to identify the best surrogate markers to permit more rapid evaluation of therapeutic strategies.