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Best first line regimen
Jan 20, 2006

Dear Doctor,

I am a 40 yr. old male. I have found out that I was hiv pos. in May 2005. My first counts were cd4 412 vl 10,000. My second cd4 was 420, no vl checked. I went to my ID Docotr on 12-14-05. My new numbers were cd4 350, vl 101,000. He is going to recheck in 4 weeks, and probably start meds. Any advice on what meds to start with. Thanks.

Response from Dr. Pierone

Hello and thanks for posting.

One of the first places to visit when exploring the data on initial therapy for HIV infection is the DHHS website. Here you will find the authoritative U.S. guidelines on HIV medical management. These guidelines s are evidence based and the recommendations evolve as new agents are developed and new studies are reported.

Presently, either an NNRTI or PI based regimen for initial therapy. Specifically, they list Sustiva as the preferred NNRTI and Kaletra as the preferred PI. For the nucleoside backbone there are a variety of choices involving AZT (yikes), 3TC (Epivir), Emtriva, and Viread.

One of the major challenges with the guidelines is that they lag behind real world best clinical practice. As an example, I suspect that most experienced HIV treaters would choose Reyataz + Norvir instead of Kaletra because of the better lipid and side effect profile. But it will be at least a year or two before the guidelines reflect this reality. Another example is that AZT is still included as a first-line agent long after studies have shown it is more toxic and less effective than other options.

But to answer your question, a good first-line choice is Truvada and Sustiva. This will be soon combined into one tablet which can be taken once daily. This choice combines potency with convenience and is hard to beat at the present time. Best of luck to you!

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