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choice of treatment for cd4~50, vl 300k

Jul 28, 2013

I had a negative elisa in 2007, always used condoms, but recently developed a salivary gland problem. I was having some weight loss as well When I read that it had an association with hiv I took a home oraquick last week. Unfortunately the oraquick came back positive. I immediately went to an ID specialist who ordered baseline labs. My elisa result "had a problem" but the western blot came back positive and the cd4 was low (less than 50) and vl was around 300k.

I immediately started Mac and pcp prophylaxis. The genotype test is not back yet, but as soon as it is we are starting treatment. I want to have the best viral supression and cd4 response Long term. I am worried about the wooziness factor with atripla as I am a professional and want to continue working. I will should be well adherent to the regimen regardless. What do you think of integrase inhibitors like stribild for advance disease? have they been working well?

What do you think of atripla vs reyataz-norvir-truvada vs stribild for a patient with advanced hiv infection and low cd4? I want the best long term outcome, especially robust cd4 response and viral suppression. Luckily I haven't been hospitalized yet and so hopefully my outcome will be better than most of the people who present with advanced Infxn and OIs.

I am way too medically educated for this infection to be so advanced (I should have taken the oraquick months ago and I was negligent in avoiding yearly testing. Lesson learned!

Thank you.

Response from Dr. Young

Hello and thanks for posting.

At the risk of not answering your question, the best regimen is the one that best fits your virus (resistance pattern, if any), your health (present or risks of cardiovascular, diabetes, kidney or others) and lifestyle (when/what you eat, work, play) and side effect aversions.

I look at options first on the basis of risks of kidney and bone disease, as these are reasons I would avoid the recommended ("DHHS Preferred") NRTI, tenofovir. If these health issues aren't significant, then the fixed-dose combos of tenofovir (Atripla, Complera or Stribild) are options.

Next comes the choices of "third agents": efavirenz, the PIs atazanavir (Reyataz) and darunavir (Prezista) and the integrase inhibitor, raltegravir. If mood or mental health issues, or requirement of nighttime dosing is problematic, efavirenz (and hence Atripla) tends to be less favorable. If taking your pills with a dietary requirement is a problem, then Complera, Reyataz and Stribild may be less favorable.

Drug-drug interactions is another area where medications are different and affect the choice of HIV meds. PIs can be most problematic here, so a careful look at the medications you currently take and risks of interactions is needed.

All of the medications you've listed (and most DHHS preferred and alternative regimens, except Complera) are very active for people with advanced disease (ie., low CD4s), so I wouldn't necessarily discriminate between regimens on this basis. Having said that, it appears that integrase inhibitors tend to result in the largest increases in CD4s (albeit a small absolute difference that has questionable clinical benefit). To your question, I'd have no reservation in using integrase inhibitors in your situation.

For more information check out's Resource Center on Starting HIV Treatment.

So, much to consider- please feel free to write back anytime. BY

declining kidney function
On ARV and Battling Dyslipidemia

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