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Low CD count
Mar 20, 2005

Dear Ben.

If initiating therapy with a CD count of less than 50,and a very high viral load, is there a combination of meds which you would strongly recommend, i.e. is there a regimen which has been clinically proven to be better for those with a low CD count, and help to quickly reduce viral load?. In this instance, would a Protease Inhibitor offer a greater barrier for resistance than an NNRTI? Another concern of mine is tolerability, so I would greatly appreciate your thoughts on which regimens are easiest to take.

As I live in Europe, I see that Truvada has now been licensed for approval over here - would this in conjunction with Sustiva prove to be a potent combination for a low CD count, and one which would offer a very high success rate?

Many thanks for your all help.

This web site truly is a godsend.

Manuel.

Response from Dr. Young

Thanks for your post and kind words.

I'm happy to hear that we're reaching readers in Europe.

In patients with very low CD4 counts and high viral loads, both non-nuke-based and boosted PI-based regimens have been shown to be very effective (as effective as in patients with higher CD4s or lower viral loads).

Boosted PIs are, as you allude, probably better than NNRTIs with regard to the risk of developing drug resistance. I tend to favor the use of newer boosted PIs in this circumstance, particularly fosamprenavir (Lexiva, Telzir) and in some cases atazanavir (Reyataz) because of their lower pill count and dosing frequency. Because of fosamprenavir's lack of diet or drink restriction nor need to avoid proton-pump inhibitors (anatacids), this medication has gained significant popularity in our clinic here in the US.

A very recent meta-analysis by Bartlett (presented at the CROI meeting last month) suggests that while NNRTI and boosted PI regimens are similar in viral load suppression, there is a significantly increased CD4 count rise for boosted PI regimens; moreover, the differences in pill count between the NNRTI and boosted PI regimens (once associated with poorer outcomes) is no longer a measure of risk of failure.

Truvada and efavirenz (Sustiva, Stocrin) has been studied in the ongoing Gilead 934 clinical study (see TheBody's conference coverage for details). This study has shown excellent results, with improved initial tolerability compared with ZDV/3TC (Combivir), though similar durability among patients who tolerate the medication. In either case, resistance profiles look acceptable though patients who do experience failure frequently have resistance to two classes (NNRTI and NRTI) of medications.

I hope this helps-- feel free to write back with additional questions. BY



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