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Just diagnosed and very concerned...
Nov 6, 2007

Hi.

I'm writing from England, UK and have just been diagnosed with a CD4 count of 37, and a viral load of 470,000.

In terms of commencing therapy, I want to start with a Protease Inhibitor combination instead of an NNRTI, as I have been advised that a P.I. offers a higher barrier to resistance. Is this correct? I am slightly concerned however that if I start with a P.I., I will have nowhere else to go if I fail initial therapy. Please can you advise your thoughts on this?

I am also looking to commence with a once a day P.I. therapy, and one which has the least side effects - which of the current combo's do you believe satisfies these needs?

Also, unfortunately, my pregant wife is in a smiliar situation to myself (She is 12 weeks pregnant). Please can you advise which is the optimum regimen in her situation.

Your work is truly inspirational.

Many thanks and regards,

Pete.

Response from Dr. Wohl

Dear Pete,

Protease inhibitors that are taken with or contain Norvir do offer the highest barrier to resistance. They are generally potent, although some data suggest Sustiva has a bit of an edge in potency against some of these PIs. I think, in your case, starting with a PI boosted with Norvir is fine. There are several once a day choices and little to indicate they are much different as far as getting the virus to undetectable levels. These are Kaletra, Reyataz/Norvir and Lexiva/Norvir. Each can be taken once a day although with Kaletra I recommend that the drug be taken twice a day at first and if well tolerated then taken all once a day. These PI options are distinguished by their pill counts, pill size and side effect profiles. Any can be taken with Truvada or Epzicom (the latter appropriate if you are found not to be susceptible to the hypersensitivity reaction to abacavir - a drug in Epizcom).

Were you to experience viral breakthrough you need not be too concerned as there are an increasing number of medications taht can be used one a PI based regimen fails. That is not to say I would be cavalier regarding treatment failure. You must take your HIV meds religiously, every day. If you experience side effects, call you clinic and if a change is in order, there are options. You also need to be on something to prevent PCP, a type of pneumonia that plagues persons with AIDS.

Your wife has basically the same options with some caveats. She can not take Sustiva as it has been linked to risk of birth defects. There are data supporting the use of Kaletra during pregnancy and this could be a good choice. It also may be convenient if you were on the same or similar regimens and Kaletra is an option for you both. There are more data for AZT being effective in pregnancy than other similar drugs. Therefore a nice combo for her could be Combivir and Kaletra. She certainly needs to be under the care of a doctor who knows about the managment of the HIV during pregnancy.

DW



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