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Opinion - Which combo to start with?
Aug 7, 2003

Dear Dr. Conway:

I was just recently diagnosed, and received my first lab results from my primary care physician. The numbers are the following:

CD3+/CD4+ Percentage(Helper) 9L 30-61 Reference Range

CD3+/CD4+ (Helper) ABS 169L 490-1740 cu.mm Reference Range

HIV 1 RNA QN PCR V1.5 Copies/ML 11311 H < 400 cps/mL Reference Range

HIV RNA PCR, QUANT 4.05 H < 2.6 Log cps/mL Reference Range

Total Lymphocytes 1832

My doctor put me on prophylaxis for PCP. I know that I have to start HIV treatment immediately. Three treatment regimens have been suggested by a HIV specialist:

1. Once daily dosing of Efavirenz (Sustiva), Tenofovir (Viread) and 3TC (Epivir). (I really would prefer once a day dosing, but are the daily drugs less effective?)

2. AZT (Retrovir), 3TC (Epivir), and Efavirenz (Sustiva). (I am really scared of the possible side effects of AZT)

3. Combivir (AZT & 3TC combined) and Efavirenz (Sustiva).

What are, in your opinion, the best med combinations for someone who is treatment naive with my numbers?

Thanks in advance for your help. You guys are great!!!

Response from Dr. Conway

Even based on today's more conservative guidelines for the initiation of HAART, you should probably start therapy in the near future.

All of the choices that have been put forward to you are excellent ones. You should NOT be worried that once daily treatment regimens are less effective. To tell you the truth, the one that will work best for you is the one you will feel most comfortable taking...Adherence is everything!!!

If you are to take the pills once a day, identify a time when you will always be able to take them. Consistency is the key.

So how do you pick? If you are afraid of the side effects of a particular drug for any reason, this is as good a reason as any to not take it. For the sake of discussion, if you go ahead with a regimen of efavirenz, tenofovir and lamivudine (3TC), you need to feel comfortable with the possible neuro-psychiatric toxicity of efavirenz, and have a plan as to how you will deal with it if it occurs. You also need to feel confident that if you ever need to switch away from this drug, many once daily treatment options will remain. This includes, for instance, a change to nevirapine, keeping you within the same clas of drug.

You will NOT be losing anything by going with once daily therapy and if you do so, you are still left with MANY options which would not force you to take your pills more often.

Good Luck!!!



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