Dear Andy, I have never taken any meds but now I think I should. My Tcell count is under 200 the last two tests (just under). My viral load hovers in the 20/30 thousand range for almost six months until which time it was under ten. The question is not whether or when, but what? What combination of medications do you recommend given that compliance will not be a problem for me? I have been told ziagen/epivir/viramune is a good combo but my doctor prefers combivir/sustiva. I am concerned that sustiva may interfere with my work due to the incidence of neurological difficulties that people experience. I am also been told that ziagen is better than AZT in terms of toxicity. This professional suggest ziagen/sustiva/epivir. What's your take?

Thanks

SG

Dear SG,

There really are many good choices for initial therapy. With your low CD4's, you should chose a regimen with proven potency and durability.

My take on the viramune/sustiva battle is that both are excellent drugs. The data are a bit better for sustiva because there are somewhat better studies, but it is likely that both are equally potent. Sustiva's real advantage may be its very long half life meaning that even if you miss a day you may be covered. The neurologic side effects are usually tolerable after the first few days, but a minority of people will have to stop. I would not recommend it to people who could not tolerate a week or even 3 of waiting for dizziness or poor concentration to resolve. viramune does not have this disadvantage, but the risk of rash is higher. Honestly, we use a lot of both in our clinic.

Ziagen is an excellent drug, but probably needs to be used in the first or possibly second regimen. It is very well tolerated, except for the small (3% risk) of severe hypersensitivity. I like the idea of ziagen, epivir viramune for you, and it would keep open a large number of options. It is probably my first choice, by a small margin. Ziagen, epivir, sustiva would be fine too, with the option to switch if the side effects were unpleasant.

Starting with a PI is still a reasonable option, although a little out of fashion. There is a good argument for saving the non nukes for second line to use with new PI's. Viracept would be my choice there.

Don't obsess too much though. You have narrowed it down to excellent choices, and you are choosing between the Barolo, the Bordeaux and the fine Cabernet... you should do well either way.