Dr Moyle

Thanks for your informative response. I am tolerating kaletra pretty well (now on 4th week) but still worried about fat problems. Also worried that if i use it now i may not be able to use it later as one doc on here says he uses it for salvage. my doc pointed ti study of how kaletra worked for 5 years w/o resistance in naive patients like me. Anyhow, so many doctors on here have said this regiment and the switch off is not what they would do. My doctor, however, said that many docs here in San Diego do it.

Im at a loss. If I did switch to the non-nuke, when could/should I? Now, or after a few months whn VL goes down ? Will it make it more likely I will gain resistance to kaletra later? Thanks for any help ypu can give! Kevin

Just because other doctors in the neighbourhood are doing something doesn't mean it's right! In medicine the most sensible way to practice is to follow evidence provided from randomised controlled clinical trials, research projects which compares a new way of treatment to an established 'standard of care'. Through this type of research based practice we can move the way which we treat HIV forward in a slow and steady manner checking and rechecking that what we are doing represents the best approach. It is certainly true that there are data showing that the combination of d4T plus 3TC plus Kaletra has been effective in a group of people starting treatment over a number of years of follow-up. However, the original study which now has around five years of follow-up included no comparison group. The study with around three years of follow-up used a comparator of nelfinavir, an unboosted PI which has been inferior to a number of other drugs, most notably the NNRTI efavirenz. There are several other combinations where long-term follow-up over many years has also been reported. That doesn't necessarily mean that those combinations are the best choice for right now. For example, there is long-term efficacy demonstrated over five years for the combination of AZT plus 3 TC plus indinavir however, we know this combination was subsequently proven to the inferior to AZT plus 3 TC plus efavirenz. Long-term follow-up from that comparative study showed that efavirenz based therapy could also provide durable viral suppression.

Now that you are committed down the Kaletra pathway and are tolerating drug well it is difficult to say what to do. My preference is always to act in a preventative way but also in a cautious way. Available evidence would say that it is safe to switch to an alternative agent such as in the NNRTI when the viral load is undetectable on two occasions a month apart. It may be now worth waiting until you have accumulated this type of a response before making a shift.

I hope this helps

Regards

Graeme Moyle