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Better not to if its not done right?
Feb 25, 2001

I am 45 yrs old tested positive 9 yrs ago been trying to deny it ever since. starting with some oi's (prostatitis, eye infections, fevers on and off, night sweats...).Went the specialist who of course recommended meds ( Crixivan and Combivir). Question is would it be better not to start with any medications if I will have problems with proper compliance with dosage regimens?T-cells 220 waiting for the viral load.

Response from Dr. Cohen

Actually, it would be better to identify what is in the way of committing to treatment, perhaps defining a combination that you believe you could take.

You have mentioned two of the three reasons why people start treatment - first is symptoms from HIV infection and the loss of T cells. Second is that your T4 count is already near 200 - and below this t cell range is where the risk of illness is not just minor temporary conditions, but major, life threatening infections. Those who have symptoms like night sweats, fevers, and a T cell count have in the past been noted to have a higher than average risk of developing one of these more serious illnesses in the near future.

However - you are right, in that if you are not ready for treatment, and do not take it at all, or take it erratically, you make get only temporary benefits, but then lose that benefit given the ability of HIV to become resistant to our meds. And then you'll be back here after some time, with a now more difficult to treat strain. So should you just postpone more?

Well, the problem is that given your T4 count and symptoms, the longer you wait, the higher the risk to you in terms of illness. And there is some evidence that those who delay starting to even lower t4 counts don't enjoy the same level of success in terms of HIV suppression when you do start.

So, what is in the way for you? The combo you've mentioned, is perhaps one of the most difficult we have in our triple combo handbook. Fortunately, successful treatment can be much simpler than what is required by that combo. Like a few pills once or twice a day. With fewer meal restrictions. For example, if you stay with the combo you mention, and simply add 100 mg (one capsule) of ritonavir/norvir twice a day, you can turn Crixivan from two pills every 8 hours without food into a combo that allows the Crixivan to be two capsules twice a day, along with the norvir and the Combivir, all twice a day with food. While you would want to drink plenty of water as well, this is one simplification we've made in the past few years. Is that what is leading to your reluctance, the scheduling? If so - would it help to know that we have several meds that are taken just once a day? There is ddI - a capsule taken on an empty stomach once a day. And the choice of one of two meds called nonnucleosides also taken twice a day - Sustiva and Viramune. And there is research going on to turn some of our other meds into once a day combinations. Would that help?

How about side effect concerns? The most common possible initial side effects on the combo you mentioned would include some nausea. And no one wants nausea. So, there are ways to make substitutions to prevent this. One common one is to use d4T instead of AZT - the latter is one of the two antivirals in the Combivir. There are many ways to alter these combos to have minimal GI upset.

Or is it the possible longer term side effects? If you are concerned that Crixivan may have side effects in the longer term that you do not want to risk, we have several alternatives to it. Other protease inhibitors. A nonnucleoside instead of the protease. Or a third nucleoside inhibitor along with the Combivir. There are options. Including research into treatment interruptions that are designed to preserve a higher CD4 count while minimizing whatever risks there are with longer term medication use.

Or is it the success rates? Well, does it help to know that our longest term studies of commonly used combinations show ongoing success in the large majority about 3 years later - and we have increased understanding into the factors that threaten this long term success - including erratic pill taking over time. Can you find a way to commit and minimize this? If so, you too can look forward to ongoing success.

Whatever is in the way for you - it is worth discussing with someone who knows this field. Since, based on your counts, there are treatment options that should be minimal in burden, and very helpful to both your current symptoms, and long term outlook.

Good luck. CC



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