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emtricitabine, tenofovir, efavirenz first line offensive

Mar 27, 2004

I use the term "first line offensive" with strong conviction to anyone considering beginning treatment. I was diagnosed HIV positive in April of 2003 and suspect having been HIV positive for some time prior to that given the last time I had been tested. I found the mental preparation and readiness of someone discerning when to begin treatment is probably the single most important decision someone who is HIV positive will make in their newly diagnosed life, short of going to get tested period. For myself and I think many others who might be in a similar boat, the two decisions seem to mark two important parallels. Getting tested="I don't want to die". Beginning the process of choosing a doctor, clinic, therapist, treatment option, this process="I want to live".

My first doctor was not the best of my early decisions. At the time I was diagnosed and during the summer after my viral load doubled 2 times (15,000 - 31,000 - 74,000) and my CD4s remained steady in the 300-350 range. While there is noted controversy and debate right now about when to begin (i.e, CD4 200 or less) the USHD Guidelines are clear that: anyone who has a VL above 55,000, has a CD4 count under 350 but over 200 at the same time, and has documented symptoms of acute HIV infection (i.e., in my case 12% body weight for the year) should be OFFERED treatment options by their physician. In the least they should be discussed. The point here is that the informed decision and discernment process should be an open dialogue between the patient and the physician even if he or she is a specialist dealing with HIV or other infectious diseases and the old philosophy of "Doctor's Orders" is not a valid one. I was not offered treatment; in fact on a faxed copy of my labs the Physician's Assistant wrote, "Dr. says no meds."

It was at that point in November of 2003 that I switched doctors and began what I feel we should all come to expect in the process and that is feeling empowered by our physicians to be open and candid enough to make joint decisions.

After a great deal of reading and learning and after talking with my new physician about the concerns I had about certain medications and their side effects, wanting to save the PIs for later, adherence, and a host of other topics we went with an unconventional treatment option - that being emtricitabine, tenofovir, efavirenz. When I began therapy in January my CD4 had dropped to 219 and my viral load remained high at 75,000. After 4 weeks of therapy my VL dropped to 238 and my CD4s rose to 328. I am awaiting my second labs since starting treatment and am hopeful for continued improved labs.

Now for the question part (steps down off his soapbox). Because I chose an unconventional treatment option, which doesn't seem to have much in the way of documented study behind it I would like to know if there are any ongoing studies or articles you are aware of with document results that could be used as a long-term gauge. My online and journal searches have not turned up much on this subject and I would just like to know if this option is gaining any popularity. In all of my searching on these forums there don't seem to be many/any others of us out there who are on this course of treatment.

Sincere and heartfelt thanks for your help and continued guidance in this area Benjamin. I found this forum and especially your responses helpful in the process of when to start treatment. I hope those who like me were worried and scared of the question find the comfort, strength and confidence that can result from informed and empowered decision making with your dr. and loved ones. All the best.

Response from Dr. Young

Thanks for your thoughtful post.

The combination of tenofovir (Viread)/ emtricitabine (Emtriva)/ efavirenz (Sustiva) is a newer low pill count option for first line treatment of HIV. While there aren't any formally presented studies on the combo, there are ongoing studies with the regimen. Certainly there is a wealth of information on tenofovir/lamivudine (3TC, Epivir) with efavirenz that shows terrific potency and tolerability (in the study called Gilead Sciences 903) and it is very reasonable to at least think that emtricitabine (FTC) will perform similar to 3TC. Some preliminary studies are at least consistent with this later statement, including a recent study that looks at tenofovir/FTC with lopinavir/ritonavir (Kaletra).

Lastly, the recent DHHS treatment guidelines also support tenofovir/FTC/efavirenz for first line treatments, and the eventual availability of a tenofovir/FTC single combo pill should make this three pill per day regimen even easier to take; so I wouldn't want you to think that what your doctor has chosen is that unusual.

Good luck, thanks for reading. BY

stable viral load / CD4 up
Timing of CD4 count

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