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What med-combo to start with?
Oct 14, 2006

I am 35 years and know about my infection since 2004. Over the last two years, my CD4 count steadily decreased. Last time, I had 390CD4/11% and a viral load of 50.000. My doc recommends to start medications although I feel great. I have a very demanding job and am really scared that my performance will drop significantly due to side effects, meaning the end of my career and the start of social descend.

Anyway, as taking meds will come sooner or later, I see 3 options and would like to hear your opinion what to start with:

1.) Truvada/Sustiva. Seems to be the "Gold standard", but I had a depression before and am scared of the neuropsychological side effects.

2.) Truvada/Viramune. Seems to be a good alternative if you don't develop a rash in the beginning.

3.) Truvada/Kaletra Taking the meds would not be as conviened as with the NNRTI's (twice daily), on the other hand, I see a chance to reduce to Kaletra monotherapy once the viral load is suppressed.

What are your thoughts and what would be your recommendation?

Thanks for a great job you and your colleagues are doing and warm greetings from the German capital Berlin

Response from Dr. Young

Guten tag and thank you for your post, our Berlin friend-

There have been very recent updates to the US-based HIV treatment guidelines (. Department of Health and Human Services and IAS-USA ).

Reviewing these, you'll find that your options 1 and 3 are among those recommended for patients in your situation. I'd not recommend number 2, since your CD4 count indicates that your risk of having a serious liver toxicity from nevirapine (Viramune) is high.

Tenofovir (part of Truvada) should be used with caution in persons with kidney disease, or risk of kidney disease. You've not mentioned anything about this, but be sure to ask your doctor before starting. Note that the old-school way of assessing kidney function, measuring serum creatinine is not sufficient for estimating one's kidney function (known as creatinine clearance or glomerular filtration rate, GFR).

While most patients who receive efavirenz (option 1, Sustiva, Stocrin) don't develop psychiatric side effects, there are case reports of such complications. For such reasons (although some well designed studies will argue to the contrary), many doctors (self included) tend to avoid using efavirenz in patients with active depression.

It's also relevant to point out that the most common type of transmitted drug resistance here in the US and in Europe is non-nucleoside resistance. In my clinic, about 10-15% of patients fall into this category.As such, it's strongly recommended that all therapy naive patients receive HIV drug resistance testing before selecting a drug regimen.

This would lead us to option 3 (or another boosted PI regimen). The IAS-USA guidelines suggest the use of a ritonavir (Norvir) boosted PI regimen- tenofovir/FTC (Truvada) with atazanavir (Reyataz), fosamprenavir (Telzir, Lexiva) or lopinavir (Kaletra). There are individual differences between the drugs and the amount of research for any particular regimen. Overall, the potency between drugs is generally similar- recent clinical studies (reviewed here at's conference coverage) have shown similarity between twice-daily dosed fosamprenavir and lopinavir and similarity between once-daily dosed atazanavir and fosamprenavir. Though some doctors differ in their read of these data, but it's my opinion that on the basis of personal experience that fosamprenavir tends to be less problematic and less diet or medication-restricted than the other options. We've started many patients on boosted fosamprenavir with two nukes and have had excellent results.

We've shifted to boosted PIs as first line treatment because of improved tolerability (compared with earlier PIs) and of distinctly better cross resistance patterns (or preservation of future treatment options) in the very rare patients who are unfortunate to experience treatment failure.

As for your question about simplification to lopinavir/ritonavir monotherapy, this strategy has garnered a lot of attention, but I think that the current data suggests that this strategy may be inferior to continuing the three (or four) drug regimens. There appears to be an increased risk of treatment failure and drug resistance. For this reason, I'd reserve the strategy for special circumstances, until additional data suggests the opposite.

So, I hope that this discussion is of value to you.

Let us know what you and your doctor decide to start.

Best of health, BY

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