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Which Regimen is Easier to Stop?
Sep 25, 2005

Hi: I've been positive for over 3 years now but haven't been on medicine. Over the years by CD4s have dropped from 800s to now around low 400s. When it goes below 350 I want to start medicine. My viral load has normally been under 60,000, but last time jumped up to 95,000 (highest ever), so I think this will be soon.

Considering that it will be almost 4 years to start meds from infection, I'm hoping I have a chance that after a period of time on medicine, I could rebuild my CD4s and then take a break for a while again. I hate the idea of being on meds forever!

You've said in other postings that it's harder to stop a regamin with Sustiva without developing resistance. My doctor was suggesting Sustiva and Truvada. What would be a better regamin if I want to stop later? I don't want to start something I can't stop!

Thanks.

Response from Dr. Young

Thanks for your post.

This is an area that has generated a lot of discussion. The concern is generated from the observation that efavirenz (Sustiva, Stocrin) can persist in the body for a very long time following discontinuation and from other studies that have shown that another long-lived non-nuke, nevirapine (Viramune) has the potential to cause drug resistance, even after single dose.

Much of the theoretical concern stems from the idea that different drugs in a triple drug combination have differing half-lives in the body. When this is the case, when treatment is stopped one or more of the medications might linger around longer than the others, potentially generating a situation of effective mono- or dual-drug therapy-- precisely the situation that can breed drug resistance.

While not well studied, the half-lives of the drugs in your proposed regimen (tenofovir, FTC and efavirenz) are closer to one another than other combos. As such, stopping this combo might not be as risk prone. For the more at risk, mismatched half-life combos, some have advocated switching out the efavirenz for a boosted protease inhibitor, because of the later's shorter half-life and diminished risk of drug resistance.

Remember that these discussions are largely theoretical ones- the actual rate of drug resistance that emerges after treatment discontinuation does not appear to be high at all, provided that one stops with an undetectable viral load.

Good luck, I hope this discussion is helpful. BY



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