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Truvada & Sustiva or Boosted Atazanavir
Sep 25, 2005

My cd4 count has recently deteriorated from a steady 400 to around 250, my VL (which has been constant for years) is around 200K. My cd4% which has been in steady decline was last measured at 16%. -Therefore I am likely to start treatment soon (UK guidelines do not suggest treatment with a CD4 count of over 350 at all) I am being offered two initial combos; Truvada and either sustiva or Ritonavir boosted atazanavir, both of which are once daily: Which, if either would you recommend?

Response from Dr. Young

Thank you for your post. It's always nice to hear from our friends from across the pond.

I'd agree with you (and your doctors) that it's time to start antiretroviral medications. You're listed some commonly used first-line treatments.

Truvada/efavirenz (Sustiva) has been well studied and presented recently at the International conference in Rio de Janiero ( Gilead 934 study) . This regimen is very well tolerated and superior to Combivir+efavirenz, a popular standard of care. The possibility of a single, triple-coformulated pill in the near future also adds to the deserved attraction. The few limitations of the regimen (and why we don't always prescribe it) have to do with the potential consequences of treatment failure-- the genesis of resistance to two drug classes, and the side effect profile of efavirenz, which can be a problem for some patients.

Of late, I've become an advocate for the use of first-line boosted PIs, with the advent of atazanavir (Reyataz) and fosamprenavir (Lexiva, Telzir). Both are being prescribed as first-line treatments here in the US (acknowledging that atazanavir is not currently recommended as such in the UK and not recommended (by guidelines) with ritonavir in the US)-- mostly because of the lack of mature data sets. Fosamprenavir is approved as a once-daily boosted PI in the States, but only twice-daily in the UK, but is also an attractive option for many patients. Both offer a change in the conventional view of PIs insomuch as having better tolerability and limited imnpact on cholesterol and triglycerides. With Truvada, the potential exists for a entirely once-daily boosted PI regimen of either 4- or 5-pills a day. The draw for many patients is the difference in resistance profiles after first-line failure-- no evidence of protease resistance and only a single drug resistance mutation-M184V (again, a limitation in the dataset is that such data does not yet exist for boosted atazanavir; only for Kaletra and fosamprenavir).

So, in the end, which would I take if I were in need of first-line medications? I'd start with a boosted PI in deference to the idea that limiting resistance would preserve my future treatment options. I tend to stick closer to presented clinical trials data (in order to avoid the unexpected)-- since favorable resistance data exists for Kaletra/Truvada and for boosted fosamprenavir (with a different set of nukes, Kivexa), I'd go this way, probably with the later. If I didn't tolerate the PIs, starting with boosted PIs by no means prevents a switch to the Sustiva-based regimen.

Just my opinions, but reflective nonetheless of how our patients view their current options. Good luck and good health to you. BY

AZT - Meningitis ?
HIV + couple w/active TB

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