I was diagnosed 5/97. I found out I have been infected now ten years, (My ex husband is positive). Up until recently my CD4 was 350 and VL 2000. In June my VL was 13,000 and now two months later my Cd4 252 and VL 23,000. My doctor suggests I start on Combivir and Viramune. I am petrified of meds and I take Xanax 1.5 mg a day for anxiety. I am super sensitive to all kinds of meds in the past, not HIV med as I have never taken any, but now it looks as if I must. Is the combination my doctor sugggested a good one and a safer one, side effect wise, or do you suggest another? Also My CBC etc. is great, why should my CD4 drop 100 points in two months? Can I wait or should I start meds right away? Thank you so much for the opportunity to ask you this and for your great web site.

While your fear comes across, there is still room for optimism that whenever you do start, with whatever you start on, you will see impressive successful results. Since that is what we usually see in those who are starting their first combination.

Combivir is two meds in one - AZT and 3TC. These are two of the nucleoside antivirals - the others are d4T, ddI, ddC and abacavir (ABC). The news of the past years has shown over and over -- we tend to see our best results overall when combining two nucleosides with some reasonable third drug. And so much of the dialog and discussion is which two nucleosides should we pick - and what should be the third drug?

In terms of which two nucleosides to use - the information available so far suggests that the two you are considering are as good as most of the options in terms of success. Issues that distinguish between the choices include initial side effects, longer term side effects, and effects on lab tests. Virtually all of the choices are twice a day combinations, although ddI is increasingly used just once a day. All of the choices are reasonably similar in terms of their potency or power - although in general ddC is thought to be on the weaker side, while abacavir is on the more potent side. (So far, abacavir has mainly been studied in the role of the "third drug" rather than as one of the two nucleosides in a triple combo.) Studies that compare various pairs of two of the above tend to show pros and cons to every choice - there is no one single winner in every category. However, it is fair to say that most clinicians usually choose between AZT/3TC or d4T/3TC, although some studies are also using d4T/ddI as another option.

Now - on to the third drug options. You mention Viramune - also called nevirapine. It is one of the three non-nucleoside antivirals we have available. Studies which use a "nonnuke" as the third drug have generally shown impressive results - and one large study which used Sustiva as the third drug showed that this combination was even better than a combo using Crixivan, a protease inhibitor. Recent studies with viramune have shown results that are similar in success to Crixivan. There is an ongoing and unresolved debate whether Sustiva is better than Viramune given these results - but at your relatively low viral load - either approach would perform well and with a high degree of confidence that your viral load will go to below detectable levels in the first few months on treatment.

Given your history of anxiety - your provider might want to avoid the use of Sustiva since of its primary side effects is an altered mood in the first few days to weeks of its use. Your combination is also pretty easy to do - just two pills AM and PM - and you are done. Now - like with any regimen - you need to take each dose to ensure you get the best chance at making it work. But hopefully this regimen is simple enough to make that an achievable goal. There are always side effect concerns -- with Viramune the major worries are a rash in the first few weeks (which rarely can be a bad rash), and a few percent of people will have liver inflammation (hepatitis) when they use this med. You should know in the first four weeks if this combination is one you can tolerate.

The other "competition" in the role of the third drug is one or two protease inhibitors. There again is great debate as to whether these meds are somehow better and therefore should be used instead of the nonnucleosides - but since that debate is still ongoing and unresolved - your combination represents one of the simplest, and well studied - as a regimen that should work as well as any.

Good luck. CC