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Starting meds
Oct 24, 2005

Ben, David or Gerald.

I wondered if you could share your experience as to the most succesful therapy you have initiated patients on who have presented to you with chronic HIV infection?

I am concerned because I have recently discovered my status, and have a low CD4 count (Less than 50) and also a high viral load (300,000+), i.e. basically, an AIDS diagnosis.

Would you normally start someone on a boosted Protease Inhibitor in my condition, or is an NNRTI better at quickly reducing viral load?

If so, which are the best and most convenient combinations to take?

I am also concerned that if I start on a Protease Inhibitor, it doesn't leave me with too many future options, as don't PI's possibly offer a greater barrier to resistance? Is that correct? If this is the case, what is next after PI's? And if the first line regimen fails, are there many "salvage" drugs available?

My last question - do you get a lot of patients who present late to you in terms of their infection, and have their lives turned around, ie, are they now living (As near as possible) normal, healthy lives?

I look forward to hearing from you.

Many thanks for your help.

Mike.

Response from Dr. Wohl

Dear Mike-

My experience and the clinical research data indicate that there is no single super-HIV regimen that out perfoms all the rest. Therapies are very potent and the great majority of patients can expect to get their viral load to undetectable levels if they are adherent to their meds.

The US Department of Health and Human Services Guidelines do list preferred regimens. These are based around either Sustiva or Kaletra. Sustiva + 3TC (or FTC) + a nucleoside analogue (like AZT or Abacavir or Tenofovir) has not been beaten in any study of people starting HIV therapy. The same holds true for Kaletra + 2 nucleosides. However, Sustiva and Kaletra have not been compared head to head in a large study (such a study is ongoing in the US).

In addiiton, there are newer therapies such as Reyataz which when boosted with Norvir will likely produce excellent results as part of an initial regimen.

So there are choices among powerful and effective therapies. Which to start with depends on side effect tolerance, other medical problems you may have, pill count, frequency etc.

Both Sustiva and Norvir boosted PIs have been shown to work even among those with low CD4 cell counts and high viral loads. There are advantages and disadvantages to starting with Sustiva versus a boosted PI and some like to save the Sustiva for later, others prefer to save PIs for salvage therapy.

I feel it is less an issue of which class of meds you use than it is what regimen is likely to work the best, the longest and with the fewest side effects. IF you are not a pill-person and really want as simple a regimen as possible, Sustiva and Truvada may be the ticket. Weighing in at 2 pills a day it is convenient and potent (and may soon be all combined in one pill). It is taken before bed, however, and that may not fit with your lifestyle.

So, then maybe Kaletra or Norvir + Atazanavir along with Truvada (or Epizcom - although must factor in uncommon risk of hypersensitivity reaction with this med)? More pills but can be taken in the morining.

See, the drugs can often be tailored to your needs. I start some patients on Sustiva and others on Norvir boosted PIs depending on what is going on with them medically and socially and their own preferences.

One thing to clarify, though, is that when you experience virologic failure on a Norvir boosted PI, almost always no PI resistance mutations are found on resistance testing. Therefore, failing a PI boosted with Norvir may NOT burn PI bridges downstream.

Can people with low counts do well? Yes. It takes more work and diligence but you can be successful for years to come. Absolute adherence to your meds, no cocaine, good food, exercise are some of the ways of stacking the odds in your favor.

DW



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