HIV Therapies. SJ Dodgson. The Journal of the European Medical Writers Association. 2003. v12.

I first heard of the HIV epidemic in the summer of 1981 when I was listening to the radio while bathing my first-born child in the kitchen sink in my apartment in Philadelphia. The Centers for Disease Control reported a strange epidemic in homosexual men, later, the risk group included Haitians, still later, intravenous drug users and now, whole African countries like Botswana. As the years passed, the main risk groups changed and life-prolonging medications have become available in rich, industrialized countries. One theme remains constant: AIDS is a deadly disease and infected persons can become resistant to all the therapies.

Two gay men living next-door to me in Sydney when I was finishing my PhD thesis are gone. I visited them when I went back to Sydney with my children in 1982 and 1983, we discussed day-to-day events and our futures as if I had never left.

For me, HIV/AIDS is about two young men, friends since kindergarten, who never reached 50, or even 40. And especially about Ian, who was gorgeous looking and loved by many men. Ian made dresses and cooked for us and learned Italian so he could teach in Italy but instead with good grace taught English in Turkey where he was sent by the New South Wales Department of Education. Graeme was monogamous and left teaching to work in the phone company. He didn’t reach 40 either.

During the early years of the epidemic I was involved in investigating carbon dioxide handling in the body. I identified mechanisms of carbon dioxide fixing and releasing in the liver, kidney, and brain and confirmed that these mechanisms work in neutrophils, which are involved in the immune system. Do they also work in CD4+ cells? Probably. I can state confidently that therapeutically disrupting the carbon dioxide handling mechanisms of the immune cells that the HIV virus hijacks has never been under serious consideration. The HIV virus is tough and when its DNA takes over a CD4+ cell, what it does is reproduce virus and destroy the ability of the body to defend itself against bacteria, fungi, other viruses and cancer. The virus rapidly evolves and rapidly can become resistant to one treatment after another.

I started full-time writing about HIV a week after the devastating cascade of events that started when 2 passenger airlines smashed themselves between upper floors of 20% of New York City office-space.

The immediate consequences of these smashes and the 2 following in Pennsylvania and Washington DC was a scaling-back of marketing writing in the center of the pharmaceutical industry, which is surrounded geographically by New York City, Pennsylvania, Washington DC and the Atlantic Ocean.

The immediate consequence to me was that within a week, the disease monographs I was writing for an advertising agency were no longer needed and a medical communications company needed a medical writer who would travel by air for their client in California.

Ten days later, I flew to southern California for a consultant meeting. The next morning the account executive drove us both north along the coast of California, past Los Angeles, to Santa Barbara to a resort, which were arguably my most luxurious accommodations. I enjoyed walking past the oleander and rhododendrons before diving into a swimming pool, then hanging out in a hot tub before bathing in my room while watching candles in the fireplace and the palm trees over the balcony at the same time. After listening to talks about the treatment of HIV from a psychiatrist, an HIV resistance specialist and a lipodystrophy specialist. The meals were terrific too.

The work with the medical communications company only improved. On the heels of the conferences in California was the 3^rd International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. A meeting with the client in Santa Barbara revealed their desire to have a presence at the meeting in Athens as well as their reluctance to send any of their own employees.

I think the whole September 11 disaster was easier on those of us who were in the middle of it; we saw what happened and we saw it being cleaned up.

Three thousand miles away in California all they knew was that all of the 4 passenger airliners that crashed were headed for California. I was not quiet about my desire to represent my favorite pharmaceutical company and report on the Athens meeting and so, two weeks later, I stepped off a plane in Athens.

The need for an annual lipodystrophy conference since 1999 highlights the consequences of taking drugs to control HIV infection. The first two classes of HIV drugs are retroviral inhibitors: the nucleotide retroviral inhibitors (NRTIs) and the non-nucleotide retroviral inhibitors (NNRTIs). The first drug with any controlling effect on HIV is known as AZT or ZDV or zidovudine. AZT was approved by the US Food and Drug Administration in 1987, since then other NRTIs have been approved and this class remains the largest. The approval of a third group of HIV drugs in 1995, the protease inhibitors, was earth-shaking for those affected with HIV and those treating affected persons. For the first time, health care providers were not routinely burying their infected patients.

Since 1995 the treatment of choice is a drug cocktail, called by the US Department of Health and Human Services Highly Active Anti-Retroviral Therapy, or HAART. This cocktail includes 3 or 4 drug cocktails from one or more classes. Since 1995, persons infected with HIV on HAART are living longer, but those infected are still at risk for premature death.

In the 1980s, HIV infection meant that death from AIDS probably would follow within 5 to 10 years. In the past few years, persons infected with HIV and treated with HAART have had increased likelihood of cardiovascular events. The question about whether the cardiovascular events result from the HIV infection or from HAART drugs remains unanswered.

In May I sent daily reports from Digestive Disease Week in San Francisco, summarizing talks on treatments for hepatitis C and HIV co-infection. The rate of co-infection is increasing, and liver failure is now the number 1 cause of death of persons infected with HIV.

The 14^th International AIDS Conference in Barcelona in July was huge and all the pharmaceutical companies were well-represented. I summarized 12 symposia in which consultants presented the industry’s newest therapies. We heard about progress towards producing a viable anti-HIV vaccine. We are not yet there, but clinical trials are proceeding and within 12 months we will know if one or more vaccines are fulfilling their early promise. Other classes of anti-HIV drugs were described, the fusion inhibitors which prevent the HIV virus from inserting its DNA into CD4+ cells and the integrase inhibitors, which prevent reproduction of the virus inside the CD4+ cell.

The most exciting part of the conference to me was sitting next to infected persons who would have been dead 10 years ago. The bottom line is that Ian and Graeme would have had a good possibility of living to 40, or 50 if they had been infected 10 years later.

I was sitting in the hot-tub in Santa Barbara in October 2001, chatting with 2 HIV physicians about the oil I had tracked from the beach into the bath-tub. I assumed that the oil resulted from some tanker spill somewhere; one of the physicians told me that the oil pre-dated settlement by Europeans, and that native Americans used it to water-proof boats. These boats were leaky and the trick was to land somewhere before the boats were swamped.

Which describes HIV therapies. HIV is a tricky disease to treat because infected persons either do not have access to treatment (a major problem in developing countries) or they can become resistant to one treatment after another. All we can hope for anyone infected is that they can stay afloat until they reach land.

This essay was first published by the European Medical Writers Association in 2003 in The Write Stuff.