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Opinion - Which combo to start with?
May 4, 2003

Dr. Young

I was just recently diagnosed, and received my first lab results from my primary care physician. 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

Total Lymphocytes 1832

My doctor put me on prophylaxis for PCP. I know that I have to start HIV treatment immediately. Three treatment regimens have been suggested by a HIV specialist:

1. Once daily dosing of Efavirenz (Sustiva), Tenofovir (Viread) and 3TC (Epivir). (I really would prefer once a day dosing, but are the daily drugs less effective?)

2. AZT (Retrovir), 3TC (Epivir), and Efavirenz (Sustiva). (I am really scared of the possible side effects of AZT)

3. Combivir (AZT & 3TC combined) and Efavirenz (Sustiva).

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

Thanks in advance for your help. You guys are great!!!

Response from Dr. Young

Thanks for your questions.

I would agree with your doctor on all points-- starting Bactrim prophylaxis is very much indicated with a CD4 count below 200 to prevent Pneumocystis pneumonia.

As for which regimen to use, this boils down to a couple of main issues.

Clearly, the comparative regimen of choice (for now anyways) is a efavirenz (Sustiva, Stocrin)-based one-- many studies have shown, and confirmed the long-term durability and tolerability of this medication when used with two nucleosides.

The question is which nucleosides to use-- the bulk of the exisiting data is to combine the drug with a thymidine (stavudine or zidovudine) with lamivudine (Epivir). Recent opinion (mine included) has really relegated stavudine to a second choice, because of side effect profiles, leading to the recommendation of using zidovudine (Retrovir) with lamivudine. Clearly, this is available as co-formulated Combivir-- dosed twice daily (1 pill twice daily) with the one pill of efavirenz at bedtime. For me, without other reasons (we'll discuss these below), is the combination against all others will be measured against.

Recent clinical trials data have shown very exciting results from the use of your first regimen, tenofovir (Viread), lamivudine (Epivir, 3TC) with efavirenz as a very convenient, three pills, once daily regimen. Indeed, for persons who would benefit from a once-daily regimen or who might be intolerant of zidovudine (either because of belief or toxicity), this regimen is my prefered alternative.

As further information accumulates (confirmation of the GS903 trial, long-term safety, salvageabilty, etc), this preference pattern might very well change.

Either way, you have some great treatment options to explore. I'd want to know if there is any chance that you could have acquired drug resistant virus before initiating therapy, particularly in light of the fact that some of the most commonly transmitted resistance in the US involves NNRTI (ie., efavirenz or nevirapine) resistance.

Good luck and let us know who things go. -BY



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