HIV's potent cocktail.

But the drugs don't spell an end to the need for inpatient care

AIDS DRUG TREATMENT HAS MOVED INTO THE ERA OF HAART, scientists' acronym for "high active antiretroviral therapy." HAART has turned a lethal disease into a manageable one, at least for now. "The new anti-viral drugs have cut the AIDS death rate by 50 percent in the last two to three years," reports Linqui Zhang, PhD, assistant professor at the Aaron Diamond AIDS Research Center at New York City's Rockefeller University.

The drugs' effect can be dramatic. "We've seen patients go from their deathbed to 'Where are we going to dinner tonight,'" says Victoria L. Harris, EdD, clinical research manager for the AIDS Clinical Trial Center at Vanderbilt University in Nashville, Tennessee. But the drugs' effectiveness won't end the need for inpatient care--and future problems with drug resistance could even promote a rebound in SNF admissions related to the disease.

The anti-viral drug cocktail targets two of three enzymes that HIV needs to reproduce. Patients generally take a combination of AZT, 3TC, and one of the protease inhibitors such as ritonavir, indinavir, or saquinavir, says Zhang. Nelfinavir (Viracept) is also a popular protease inhibitor. Clinical trials are also trying different combinations of available HIV fighting drugs including a protease inhibitor sparing regimen to leave a class of medications for future treatment.

Researchers are hunting for a drug to target HIV's third and perhaps most critical enzyme, integrase. "Integrase allows the HIV virus to integrate with the cell's DNA structure, so that when the cell replicates, the virus replicates," explains Robert Belshe, MD, chief of the division of infectious disease at the St. Louis University School of Medicine.

So far, the new drug arsenal has changed the landscape of AIDS care. "As a result of the new combination therapies, we have seen a dramatic--and I mean dramatic--shift from inpatient to outpatient care of people with HIV," Belshe reports.

As a result of the new drugs, Bailey-Boushay House in Seattle, a SNF dedicated to AIDS care, now has beds available for other types of medically complex patients. "Today our patient mix is 65 percent AIDS and 35 percent non-AIDS," reports administrator Christine Hurley.

The drug therapy's near miracles don't come without a high price, however, both in dollars and toxicity. The medications--up to 25 pills a day--cost $1,500 to $2,000 a month. And "some people are very sick because of the medications, which can be as grueling as cancer chemotherapy," says Hurley. "Mostly, you see chronic gastrointestinal problems, skin problems, incredible fatigue, all of the things that make people miserable." The Seattle facility is also seeing new cases of hypertension, diabetes, and high cholesterol caused by the treatment.

Even so, the enzyme fighters have provided the first glimmer of light at the end to the tunnel. But the journey to a cure is far from over, researchers caution. Studies show that the combination therapy cannot wipe out the last vestige of HIV in the body.

This hidden viral pool can mutate into drug-resistant strains, although the incidence is low in patients who take their medications as prescribed. Patients who take a vacation from the daily medications or skip doses, however, can quickly develop drug-resistant viral strains.

Resistant stains could push AIDS care back into the inpatient realm. In fact, most of Bailey-Boushay Houses's patients require skilled care because they could not tolerate or comply with the new drug regimen. "We find that people with behavioral or addiction issues are the sickest with AIDS today because they are not usually able to comply with the complex combination therapies," Hurley reports.

Meanwhile, the search is on for that magic bullet to eliminate the virus altogether. Several approaches are under investigation, Zhang says. One strategy is to use antibodies against T cells (white blood cells), where the virus resides.

Other researchers are applying immune-related technologies such as adding a vaccine to boost the patient's immune system to keep the virus in check.

The key to ending the epidemic is a preventive vaccine, which is Belshe's area of research. "What we really need is a safe effective vaccine that can be administered to everyone," he says. "It's still a ways off, but we are making progress."

Karen Lusky is a contributing writer to Contemporary Long Term Care.

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CDC guidelines. To see an updated version of HIV treatment guidelines from the Centers for Disease Control and Prevention--Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents--cheek out the Web site of the AIDS Treatment Information Service at [less than]www.hivatis.org[greater than].

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