After considerable time ignoring my HIV positive state I have decided to begin medication. My VL is 380,000 and my CD4 is 212. To date I have had no health issues other than minor dermatology related problems. My doctor has recommended Combivir with either Crixivan or Viracept. Which of these or other combinations would you recommend to someone who has never had therapy and wishes to bring the viral load down fast to undetectable levels and offer minimal side effects?

Well - the first issue is that it is great you are ready to start. Based on your numbers - your immune system needs the help before even more damage is done. And based on what we have learned, much good can be done with these meds particularly for someone in your circumstance.

However - there is no 'best' combo. If there was this web site would be a lot briefer (just take these three meds and no more worries...) Both of the combinations you mention work well - with both we have much info to be confident about both, but some info to make us a bit more worried about your success given your higher viral load - but still - either approach usually works. And there are plenty more combination in addition to those two - both those available by prescription as well as those still under investigation in studies.

So - how to choose? Well - one way is to learn what schedule these meds would ask of you - and try to take something other than these meds on that schedule to see how well you can do this. Crixivan in particular is more demanding of you - it must be taken about every eight hours - with minimal if any food - and with 48 ounces of water per day. Viracept is less demanding - either three pills three times a day, or five pills just twice a day (about every twelve hours or so) with food. And - other protease inhibitors (PI's) can be just twice a day - including Fortovase and the soon to be released amprenavir. (since the combivir is just twice a day, it could make it easier if everything else can be taken twice a day as well...)

But - given your higher viral load - some clinicians might recommend a dual PI approach - the best tested has been ritonavir with saquinavir, but recent info suggest ritonavir with indinavir looks powerful as well, and the addition of ritonavir to indinavir allows both to be taken just twice a day, with food (and maybe even without the water requirement...)! And there are still other combinations of two PI's like nelfinavir and saquinavir, and so on. And there are new PI's in testing that look promising - like ABT378 for example which is entering studies all over the world which looks to be among the most potent PI's yet! You might consider investigating to see if any of these study sites are near where you are...

And there are even some combinations tested that show benefit without a PI - like using Combivir with abacavir, or any of the nonnucleosides. And there are alternatives to the Combivir as well that for some have a bit less stomach upset - like d4T instead of the AZT which is one of the two meds in Combivir. And ddI can be taken just once a day - which for some is a plus. And at least two of the nonnucleosides can be taken once a day - so you could put most of your meds just once a day. And so many studies of new promising combinations are going on in most major cities - each could be worth at least a call to see what new options there are -- since many of these studies are ways to even further improve on what we already have.

And on it goes. So much to choose from. Since there is no single best, you and your provider must choose somehow. What is clear however - is that all of these can work well - BUT each will only do its best if you can meet what it needs from you -- which is to be able to take each of the doses each day. Whether it is once, twice or three times a day. With or without food. And so on. Especially with your higher viral load - it is important to keep the pressure on the virus. So - doing your review and planning NOW - before you start - ensuring you can do this - can be worth the time to ensure that whatever you pick can work.

good luck. CC