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Which combination to start?
Mar 16, 2002

I seroconverted to be HIV positive in September 1993. My heath has been good and largely unremarkable except for a rare outbreak of genital herpes. In November 2001 I suffered from a 5 day fever with a rash that lasted 3 days. Since then I have developed a persistent cough and shortness of breath of no known cause. My herpes outbreaks are now frequent and I have facial seborrheic dermatitis. My last test results are Jul-99 CD4+615 VL 90600 ; Dec-99 CD4+400 VL 167200 ; Apr-00 CD4+450 VL >750000 ; Jul-00 VL 163800 ; Mar-01 CD4+294 VL 112200 ; Jun-01 CD4+208 VL 179000 ; Nov-01 CD4+187 VL 324000.

In light of my deteriorating health, and decreasing CD4+ I feel I am ready to start therapy. I am ART nave. I have been trying to determine which combination I should start on. I have been to several HIV doctors to discuss commencing therapy and I hoped to achieve consensus on a starting combination. Unfortunately there was little common agreement and each physician had a preferred treatment strategy and combination. Some physicians felt with such a high VL I needed a PI based regimen, others suggested an NNRTI based regimen and yet another wanted a NRTI based regimen.

I have two questions: (1) What treatment strategy would you recommend? and (2) What specific combination of drugs would you recommend? Thank you in advance for your reply.

Response from Dr. Young

Thanks for your question. I'd certainly agree with all of your physicians that starting therapy now makes sense.

With a viral load of 300,000, I'd put you in the high viral load category. Which combination to start really depends a lot on your preference and the experience of you prescribing physician. There is data that supports using NNRTIs (mainly efavirenz- the Dupont 006 trial)as well as PIs in persons with high viral loads(though a recent analysis suggests that nelfinavir many under-perform in this situation). I'd likely avoid Trizivr therapy for now, since at least one clinical study suggested that the regiment did not do as well for persons with high viral loads as for persons with lower viral loads.

One approach that we've taken for persons with high viral load has been to use four-drug regimens-- the availability of fixed-dose combinations (like Trizivir or Kaletra) has made this easier to take and stomach; though there is currently a paucity of data that tells us if 4 is better than 3.

Good luck, BY


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