Immune modulation in HIV infection: fact or fantasy?

Since the recognition of AIDS a decade ago, many have postulated that immune modulators would provide the therapeutic intervention necessary for preventing disease progression and death. However, despite rapid advances in our understanding of disease pathogenesis and significant achievements in the area of antiviral development, immune modulators remain largely the subject matter of philosophical editorials rather than of definitive efficacy studies. More than 50 agents have been examined to date, yet only the colony-stimulating factors have proved useful in neutropenic patients with infection with human immunodeficiency virus (HIV). Other agents, such as isoprinosine, have provided conflicting data, whereas immunosuppressive agents, such as pentoxifylline, are presently under study. Cytokines examined prior to the development of antiviral agents were disappointing. Further studies examining these cytokines in conjunction with antiviral agents may be more rewarding. Other applications of these agents may be as adjuvants with vaccine administration or antimicrobial agents in the setting of opportunistic infection. To date, however, the data would suggest that there will be greater advantages from antiviral agents that prevent the development of immunosuppression than with immunopotentiators, which try to boost the embattled immune system.