I have been HIV positive for 6 years with a viral load of never less then 26,000.My doctors(and there have been several due to various circumstances) have all had no interest in doing anything for me but try and get me to start on meds.I remain healthy and symptom free but my viral load is at 700,000 and my t4's are 320.If I had started meds in 96 I would proably be in a much worse state with drug resistance, toxicity and side effects.I now feel that I need to start meds but since they were wrong before how can I trust them now.My doctor tells me that with a combination of sustiva and combivir I will have a couple weeks of mild to medium side effects and little chance of resistance and liver or kidney toxicity in the years ahead.This sounds way too simple.What is your opinion? My last CBC was all within the normal range.Thanks for your opinion and your great work.

Thank you for your questions-

I agree with various aspects of your question; namely, that HIV treatment approaches are constantly evolving- what was considered state of the art in 1995 clearly is not state of the art in 2001. Indeed, it is fair to say that many who received treatment before potent cocktails did suffer from the emergence of drug resistance and the subsequent loss of other treatment options, through cross resistance.

It is important to look critically at the risks and potential benefits for treatment at any given time, for any given person. What we are faced with in 2001 is an increasing appreciation that treatments are firstly very potent and can restore or preserve immune function- indeed have been unequivocoally shown to save lives. These treatments are not perfect- the requirment for near perfect adherence and the risk for the development of drug resistance or toxicities remain large issues.

Nevertheless, most experts (this one included) would agree that for someone with a CD4 count below 350 with a high viral load (like yours- remember that the average viral load is only 50,000; yours is over 10 times this number)- the benefits of combination treatment far outweight the potential downside. The regimen of Sustiva and Combivir that you've (or your doctor) proposed is a very proven combination- in pivotal clinical studies (DMP-006, for example); the rates of viral suppression are greater than those seen with a protease inhibitor-containing regimen; the rates of discontinuation and viral resistance are very low. In a recent presentation at the Retroviral Conference, it has been estimated that after 6 years on this regimen, more than 50% of patients who initate treatment with Combivir/Sustiva will remain with undetectable viral loads. In our practice, this regimen is very well tolerated, save for some early side effects (that you've very accurately described). The vast majority of these side effects are managable and are gone within a few weeks. Some persons have fatigue and anemia associated with the ZDV component of Combivir- laboratory monitoring should assist with the management of these.

In sum, the decision to start treatment is a team decision- which medications to use, education as to how to take them, adherence and how to manage side effects. Stay informed about your choices and keep your doctor informed as to your symptoms and side effects- all of these translate to improved outcomes and longetivity of treatments.

Good luck, BY