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I have to choose a drug for first regimen
Mar 4, 2007

i was diagnosed three months ago of aids, 15 cd4 count and 270,000 vl load. My hiv doc wants to put me on the med next week, and he gave me two best choices. Raytaz, Norvoir booster, and Truvada,,,,,, or Atripla. I read that the first option has lesser side effect, but I read some bad things about norvoir. I am mostly worried about being fatigued or getting lipostrotphy on these drugs. Which one do you reccomend?

Response from Dr. Pierone

By now you have made your choice but here is some more information to consider.

Starting regimens are generally either NNRTI-based (Atripla) or PI-based (Novir/Reyataz).

Atripla is the combination of Emtriva (emtricitabine), Viread (tenofovir), and Sustiva (efavirenz). This very effective regimen is administered as one pill taken at bedtime and should be considered the standard by which to judge new and alternative HIV therapies.

But there are several legitimate reasons why Atripla may not be the best first regimen for everyone with HIV infection.

1. Transmitted drug resistance. Some people become infected with drug-resistant HIV. If so, there is a good chance that Atripla would not be as effective. It is now considered a standard of care to have a genotype or phenotype before starting HIV medications to guard against the possibility of drug resistant virus.

2. High viral load and low CD4 count. This may apply to your situation based on your numbers. Several studies show a slight drop off in effectiveness of NNRTI-based therapy when the viral load is very high and CD4+ lymphocyte count is very low. Not every study demonstrates this, and those that do show only a small decrease in success so this is not a deal killer.

3. Women of child-bearing age. In primate studies, Sustiva has been linked to birth defects, some quite severe. Congenital malformations have been seen in infants born to women who were exposed to Sustiva during pregnancy. This drug carries a pregnancy category D (don't use) designation because of these issues. So women who are planning or potentially planning to have children should steer clear of Sustiva and Atripla.

4. Active moderate or severe depression. Uncomplicated depression is not a strong reason to avoid Sustiva, but this should be taken into consideration because this medication may exacerbate depression.

5. Adherence challenges. It may be very difficult to predict the future ability to adhere to a daily regimen, but for individuals who have adherence challenges, there is clearly a greater chance for treatment failure and development of viral resistance on a NNRTI-based regimen as compared with a PI-based cocktail. So some clinicians will recommend a PI-based regimen for patients that have risk factors for poor adherence.

All of that said, Atripla is generally better tolerated than PI-based therapy, is highly effective, and would be an excellent first choice.



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