Dear Dr Bob

I am a 32 year old hiv + male from the UK. I started treatment in March of this year and my specialist has put me on a regime of truvada and nevirapine (Viramune). Initially I was taking my truvada and one 200mg nevirapine in the morning and one 200mg nevirapine in the evening. My doctor then suggested I try taking both nevirapine tablets in the morning - something I was very happy to do as I always take my meds at the same time every morning whereas my evenings are so haphazard I couldn't rely on taking them at the the same time.

I had a blood test taken a few weeks ago to check the levels of nevirapine after 24 hours in my system. My doctor called today to say that the level was low and has suggested that I either up the dosage to 600mg in the morning or go back to taking 200mg twice a day. My latest cd4 count is 508, VL 103 and 34%. I'm guessing I haven't reached undetectable yet because of the low levels of nevirapine? My concern is that if I up the dosage of nevirapine I will be putting myself at greater risk of side effects/liver damage etc... On the other hand, I would rather take my meds in the morning as I know I will not miss a dose (haven't yet and take them at exactly the same time every morning -OCD!!) I'd really appreciate your angle on this.

Thank you in advance for a response and for all your wonderful work on this website.

Dave

Hello Dave,

I would agree that going back to twice-a-day dosing might be problematic for you, because your evenings are "so haphazard." Consequently this is not a good option. I would also be reluctant to increase your morning Viramune dose to 600. There are other once daily options you could consider. This would involve a change in your regimen; however, in light of your very low plasma viral load and good CD4 count (508), there should be no real risk involved. Certainly if your Viramune levels are falling into the sub-therapeutic range, there is a very real risk you could develop resistance to Viramune, as it has a low resistance threshold. I would suggest you talk to your HIV specialist about other once-per-day regimens, such as Reyataz/ritonavir plus Truvada or Kaletra plus Truvada, for example. Atripla was the first combination pill (three drugs in one) approved for once daily dosing. However, most HIVers prefer to take Atripla at night rather than in the morning to help with side effects. Atripla, however, would indeed be another option for you. It can be taken in the morning if you are not bothered by the side effects. (Some folks have absolutely no noticeable side effects with Article.) Bottom line: There are a number of effective combination antiretroviral regimens that can be taken once daily.

Good luck Dave. Be well.

Dr. Bob