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Treatment Options
May 1, 2003

Dr. Wohl

I just received my first lab results from my primary care doctor. The numbers are the following:

CD3+/CD4+ (Helper) 9L 30-61 Reference Range

CD3+/CD4+ (Helper) ABS 169L 490-1740 cu.mm Reference Range

HIV 1 RNA QN PCR V1.5 Copies/ML 11311 H < 400 cps/mL Reference Range

HIV RNA PCR, QUANT 4.05 H < 2.6 Log cps/mL Reference Range

My doctor put me on prophylaxis for PCP. I have an appointment with a HIV specialist in one week. I know that I have to start HIV treatment immediately.

What are, in your opinion,the best med combinations for someone who is treatment naive with my numbers?

Thanks in advance for your help.

Response from Dr. Wohl

Thanks for writing in. Your doctor did the absolute right thing by placing you on PCP prophylaxis before you saw the HIV specialist.

There are plenty of treatment options available. If you live in a city or other place where you can become involved in a clinical research trial, I'd consider it. Overall, participants in such studies tend to do better than those treated outside of trials. Of course, you must look over the study closely to make sure it is well designed and offers therapies that are likely to be successful (you can always run any study you are considering by us).

If a study is not available or not your cup of tea, initial treatment could be grouped in several categories based on what class of HIV drugs is or is not included in the regimen. For instance, protease inhibitor-sparing combinations have become popular given the impressive results seen with non-nucleosides (e.g. efavirenz, nevirapine) in clinical trials. Two nucleosides plus a non-nuke will likely do you just fine. The once daily dosing of efavirenz, tenofovir and 3TC has made this an increasingly popular choice.

Most all other options right now will involve twice a day regimens. Probably the most popular combo for someone with your numbers in the US would be AZT+3TC+efavirenz. If there is any trouble with this non-nuke, its classmate , nevirapine, can easily be substituted instead.

If your viral load was much higher, I might consider a combination that included Kaletra. This is a potent protease inhibitor and a titan that has not been compared head-to-head against non-nukes in any large study (although such a trial is just starting in the US).

Nucleoside-sparing regimens are used by some clinicians and have theoretical justification but the long term value of such a strategy compared to others is not yet known.

On teh other hand, recent data indicates that an all nucleoside regimen of AZT+3TC+abacavir (Trizivir) is not as potent as a non-nuke based regimen and is not a first line option for a motivated patient willing to do whatever it takes to get their viral load down and CD4 cells up.

Of course, much depends on you. I hate to place the burden at the feet of the patient but with so many options personal factors - such as work schedule, anticipated tolerance for particular potential adverse effects, lipid profile, concomitant illnesses (i.e. diabetes, hepatitis C, mental/emotional disorders), adversion to pill taking, etc - all influence the choice of what will hopefully be a combination you will be on for many years.

Let us know what you choose to do and how it goes. DW



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