Dear Doctor, My HIV status is the following: dianosis=1 month, CD4=320, VL=35,000 symptoms= daily fever, some weight loss, mononucleosis. My MD suggests I start medication right now. Options: AZT+3TC+Efavirenz OR AZT+3TC+Nelfinavir. I want the most effective combination with the least probable serious side effects. Which combination do you suggest? Thank you very much for your help. God bless you.

The good news is that both combinations are likely to work very well. Both combinations have only a rare chance for serious side effects. There is in fact a clinical study in the US that is comparing these two approaches (it also compares using d4T plus ddI instead of the azt/3tc while still comparing the efavirenz versus nelfinavir). That study happened because these researchers felt that these were among the most attractive combinations in terms of most likely to work, and least risk for problems.

They have different side effects however. As we have discussed on this forum, the efavirenz/sustiva has a risk of altered mood/dreams for about half who take it - but it tends to wear off in days in not a few weeks in almost all. The nelfinavir has a risk of diarrhea in many - altho we in Boston and others are doing a study of pancreatic enzymes to see how often we can fix that problem. And some will have an increase in blood fats - cholesterol and triglycerides - while taking it.

The AZT has a chance of nausea in the first month - so take it with food - and a small risk of decreasing white cell/red cell counts - so getting a blood test in the first months is important just to check. And 3tc thankfully has few if any notable side effects in the majority.

And then there is lipodystrophy - changes in body shape. While we initially thought it was due to the protease inhibitors, including nelfinavir, now we are not so sure. So we are still learning more about the long term side effect issues.

So - which is best? No clear answer yet - but both are pretty easy - a handful of pills twice a day. Nelfinavir requires that it be taken with food probably close to every 12 hours (or three times a day if you prefer) - while Efavirenz is three capsules once a day.

Two good choices. Good luck with whatever you pick.

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