May 23, 2001
Dear Dr.Pavia, Thank you for that quick answer. Valeria is writting to you again. When i started ART in 1999 the only available drugs in my country (Bulgaria) were Retrovir, Epivir and Invirase, later Combivir. As my viral load was 120 000 and my CD4 cells 290 that time I had no choice. The situation now is not much more different - almost all nucleoside ananlogs are available, but from PIs only Invirase, Fortovase and Norvir, NO non-nucleoside analogs. I know that this is a big absurd but as i do not have money to buy the drugs by myself I am supposed to take what I have or to take nothing at all (I have my drugs now free of charge). Another problem in Bulgaria is that there is only one doctor who is responsible for all people with HIV/AIDS in my country (more than 400). So the only thing I can do is educating myself and looking for people like you ready to help. I think the option to add Norvir to my current combination(Combivir,Invirase) is the best one I have. At least this combination still works for me and Norvir will improve its work. I know that the best studied regimen is 400mg Norvir/400mg Invirase twice daily. I also understand that the regimen 100 mg Norvir/800-1200 Fortovase/Invirase twice daily is still under stadying and that the choice is mine, the resposibility too. What about if i just add Norvir 100 mg twice daily and contnue taking Invirase 600 mg tree times daily? Would Norvir do its boosting job in such a regimen? If you see a better option for me among the drugs I mentioned above just let me know. Thank you once again. With best regards, Valeria
Response from Dr. Pavia
Thanks for your update on the situation in Bulgaria. I wonder about the politics that determine what drugs are available.
You don't mention your viral load right now. If your viral load is undetectable, then adding norvir is a great idea, and should help keep you undetectable longer. However, if your viral load has risen to close to where you started, I worry about doing more harm than good. The most interesting situation, but the hardest one is what to do if your viral load is now low, but detectable, say, 1000-10,000. In that setting, you may be able to get a better response by boosting the saquinavir. This does work with indinavir (crixivan) and norvir.
As for doses, I can only make some suggestions. I would probably not use norvir twice daily and invirase 3 times daily, just to avoid the complexity. Based on the curves from once a day studies, I would probably consider 100 mg norvir with 600 mg saquinavir (as fortovase or invirase) twice daily. It should give you excellent levels, better convenience and make it easier not to miss doses.
I hope this helps. Good luck and keep asking good questions
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