Dr Wohl: What do you think of this combo? FTC (emtriva), Atazanavir (with low dose norvir) and viread. I am treatment naive. VL 450K and tcells 350. I dont want to start any yet but my doctor says not taking action is like watching house burn down. Kevin

Kevin

Dear Kevin-

IF you are asymptomatic (have no symptoms of HIV infection), I would disagree with the analogy to the burning house. Rather, I would say that your house could use a few more sprinklers and an extra fire extinguisher or two in case it catches on fire some time in the (near) future but at the moment there is no smoke. However, I agree that your viral load is very high and this would also lead me to urge therapy in the short run.

The combo of tenofovir (Viread) + atazanavir (Reyataz) + 3TC seems like a natural given its convenience but the rub, as you know, is that there are recent data that indicate tenofovir reduces the levels of atazanavir in the blood by at least 25%. This is a bummer. Using low doses of the drug ritonavir may boost atazanavir levels (as it does for other protease inhibitors) to more comfortable levels but an attractive aspect of atazanavir is that it does not lead to lipid or glucose abnormalities. Adding on ritonavir will likely null and void this advantage. Additionally, this is not a combo that has been well studied, particularly in persons with high viral loads.

I'd urge you to talk to your clinician about a slightly more conservative approach with either tenofovir + FTC + efavirenz (Sustiva) - these are also all once a day. An alternative I would also feel more comfortable with than what you have been recommended would be 2 nucleosides (e.g. Combivir, tenofovir + 3TC or FTC, etc) + Kaletra.

Discuss these alternatives with your doc and your concern over the lack of efficacy data regarding the combo he/she is suggesting.

DW