FIRST LINE THERAPY FOR CD4 COUNT 11
May 18, 2002
My aunt has recently been diagnosed as HIV+ after a long period of ill health during which time she has been on and off treatment for cholera amoebiasis malaria etc. Her cd4 count last week was 11 and she has clinical symptoms of AIDS - candidiasis, wasting, diarrhoea>2/12, nightmares, etc possibly AIDS related dementia complex. What is the best regimen to start her on? She currently could not eat, was vomitting but has been on IV fluids/ glucose for three days now and can eat soft foods. Should we commence HAART and what drugs? Thanks in advance
Response from Dr. Young
Thanks for your question.
I'd think that it is definately time to start on HAART. What to start on is somewhat debatable, and clearly we'd want to select a regimen that will be both very potent and well tolerated. That you aunt can now eat soft foods, means that we could initiate HIV medications- could even consider a combination that could be administered as an elixir, if swallowing remained a problem.
In this particular situation, some would argue that the best data for immune reconstitution from very low CD4 counts is for protease inhibitor-based regimens-- this is not to mean that other types of regimens won't work, but simply that this situation has not been well studied yet.
I'd probably favor a 2- or 3-NRTI regimen with a protease inhibitor (perhaps boosted; we use Combivir or Trizivir with either nelfinavir or Kaletra in this situation; the particulars would depend a lot on your local doctor's experience and practice habits. If she is having severe nightmares, it might be adivisable to avoid efavirenz, which might exacerbate the situation. I'd also want to be sure that your aunt is receiving good care for her candidiasis (fluconazole, for example) and aggressive nutritional support -- with agents to improve appetite (megestrol or dronnabinol).
I hope this is helpful, good luck and stay in touch. BY
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