change from a 4-drug regime to a 3-drug one? Reason: my insurance no longer has a fixed copay amount for drugs but rather a percentage of the price so my monthly drug cost has increased significantly. I am currently on Viread, Epivir, Sustiva and Viracept. This is my second combo, changed not because the first one had failed but because of side effects (lipodystrophy). I was first on Videx, Sustiva, Viracept and d4t. When I went into meds, I had 15 T cells and viral load close to 800,000. After 3 months on my first regime, I was undetectable and have remained since (over 6 years) My CD4 count has been in the upper 800 for over 4 years. I wonder if I could cut down to 3 meds without jeopardizing my current numbers. And, if so, which one would I cut?

Thanks for your post.

Given that you've never experienced treatment failure (virological failure), it's unlikely that you have any significant risk of having drug resistant virus.

With this assumption, you should have the ability to simplify your regimen in a number of ways. Right from the start, you probably don't need to be on both a NNRTI (efavirenz, Sustiva) and a protease inhibitor (nelfinavir, Viracept). I'd consider dropping one of the two, and if having a simple regimen is of interest, then the nelfinavir would be my choice to discontinue.

Dropping the nelfinavir would permit you to be on a well-tested regimen of tenofovir + 3TC + efavirenz; 3 pills once-daily. Further to the idea of simplification, you could consider consolidating the tenofovir and 3TC to the fixed-dose combo pill, Truvada (tenofovir + FTC). This would leave you on a guideline-recommended, two pill (and two copayment) regimen of Truvada + efavirenz.

I don't think that such simplification strategies would place you at any significant risk of treatment failure or jeopardy of your CD4 health. That said, any time that I switch my pateint's medications, I'll monitor their symptoms and labs closely for a month or so, just to be sure.

I hope this helps, good health to you. BY