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Which haart regimen to choose for treatment naive patient
Apr 24, 2014

Hi doctor, thanks for your recommendation. I have decided after some research as well as based on your recommendation that I would start the treatment. My next visit in early May would be to review my genotype results and decide on the drug to use. To recap, my viral load during acute stage was 2 million copies and cd4 at 295 counts. Here are a couple of questions I wish you could advise to help me on making the right decision: 1. Assuming no preexisting resistance, is there specific drugs recommended? 2. I understand atripla is currently the standard recommended drug but complera and striblid are good options too. As my major concern is the long term toxicity, may I understand which drug is known to be more tolerated? 3. Are all once daily pill have the same effect of lipostrophy? If not, which has the best chance to avoid it? 4. My social worker informed me the standard combination being used nowadays are epivir sustiva and Viread. Do they work similarly as atripla? 5. Do all the once daily pills have the same ability to cross the blood brain barrier, and if I pick the ones that do, would I have better chance to avoid hiv related brain damage? 6. Do you think by taking supplements and the right food, I would be able to reduce the side effects eg heart diseases and diabetes?

Thanks a lot for your kind assistance in answering my questions.

Response from Dr. Young

Hello and good to hear from you again.

There are a lot of factors which go into choosing a first line regimen. Current US treatment guidelines recommend (or call "preferred") seven different regimens- 1 using a NNRTI (efavirenz), 2 with boosted PIs (atazanavir or darunavir) and 4 with integrase inhibitors. The US Department of Health and Human Services recently updated their guidelines to include 4 integrase regimens.

In my opinion, the days of general use of first-line NNRTIs and PIs in the US are waning and integrase inhibitors (raltegravir, elvitegravir and dolutegravir) should not be the basis for all preferred first-line treatments. This is because of a number of studies which have shown significantly better tolerability and statistical superiority of the integrase inhibitors over efavirenz (2 studies) and PIs (2 studies). None of the newer regimens are particularly associated with increasing risk of lipodystrophy; I haven't started a new patient on Atripla for many years because of efavirenz-related side effects.

I'd recommend looking over the list of possibilities- there's only one single pill integrase regimen right now (Stribild), but another by end of summer (with dolutegravir, abacavir and lamivudine).

This discussion is aimed at US-based patients; in other countries, other medications are typically used. In my opinion, this is because of price considerations. (If you live outside of the US, please write back and we can go through this further.)

As for supplements and food, you can read my other posts about supplements. In general, most people in wealthy countries don't need to take any supplements, unless there are documented vitamin or dietary deficiencies. The most common are vitamin D and calcium. All the others are very rare- and the marketing around the is based on limited or false science.

Most new medications aren't commonly associated with frequent side effects, though GI side effects are usually minimized if pills are taken with food.

Reducing the risk of diabetes and heart disease means more about good diet, exercise and avoiding obesity and (in the case of heart disease) tobacco.

I hope that's a helpful start. BY

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