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First Line Therapy For Treatment Naive
Jan 31, 2005

Hello Doctor,

My specialist is recommending that I begin therapy within the next few months. My current CD4 cell trend is about 310 to 340 (18%). In the four years I've known my HIV status my viral low has always remained very low, around 1000 to 2000 copies. I recently had a genotype done and it showed I had "wild type" virus with no mutations which I know is favorable news. I'm also completely asymptomatic and otherwise in good health. My doctor considers me to be a very slow progressor but she does feel I'm at the threshold of initiating therapy. Based on this, is there a "gentler", easy to take regimen for someone with a very low viral load like myself? I have all the usual concerns about possible drug toxicities and want to make the best choice possible. Also, do you feel I have a good long term prognosis?

Response from Dr. Young

Thanks for your question.

I'd agree that you're at the threshold for initiation of HIV treatments, though with your low viral load, there isn't a real urgency to start.

Many of the newer HIV treatment regimens are much "gentler" than those in previous years-- non-nucleoside-based treatments (those that include either efavirenz or nevirapine) are clearly an improvement from first generation protease inhibitors; newest protease inhibitor-based treatments (those that include either atazanavir or fosamprenavir) are also dramatic improvements from earlier days. Because of these newest PI advances, many of my treatment naive patients are now electing to start first-line treatment with a ritonavir-boosted PI, usually fosamprenavir. In my opinion, while PIs have a slightly greater risk that you might have some side effects, this increased potential for side effects is offset by the dramatic reduction in the risk for developing multi-drug resistance is you are unfortunate enough to have treatment failure.

Nucleoside options have expanded recently, with the approval of Truvada and Epzicom-- new fixed-dose combo pills. These medications in conjuction with the older, tried and true Combivir offer ease of administration, fewer pills and lower copayments.

What we do in selecting treatments is to balance off many factors, including aversion to side effects, both short-term and long-term; need to avoid dietary restrictions or drug-drug interactions.

The fact that you have a wild type virus with a low viral load is heartening, though this simply means that you have the pick of the litter in terms of ARV choices. Each treatment option carries with it a balance of benefit and potential risk. All contemporary treatments are in general, well tolerated, and very potent-- I'd ask your doctor to review the specific attributes of treatments with you with attention to the specific issues that make you an individual.

Good luck, BY



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