Jul 26, 2004
Thank you for the excellent work you do on this site. Your help is really appreciated.
For those starting their first HAART regimen and wishing to start on a PI-sparing combination, it seems that Combivir/Sustiva has always been an excellent choice. However, I seem to be hearing of more and more people starting with the combination of Viread/3TC/Sustiva. Given the opportunity for once a day dosing, low pill burden, a (relatively) low side-effect profile (particularly when compared with AZT) and a lower risk of developing lipoatrophy, do you now favour this regimen as a starting regimen or hasn't enough research been conducted to determine the long-term efficacy of this combination?
I have no prior drug-resistance to any HIV meds and would like to take this combination when the time comes for me to start meds as it seems so attractive compared to other combinations.
Response from Dr. Young
Thanks for your question and kind comments.
You've mentioned a couple of the most frequently prescribed first-line treatments. The later regimen (tenofovir/3TC/efavirenz) is indeed a well tolerated and well studied combination. There is no direct study (yet) to compare tenofovir/3TC (or FTC) to Combivir, hence any statement about risk of lipoatrophy seems premature to me. There is ample evidence, however, that shows that versus d4T, tenofovir-based treatment (at least with 3TC and efavirenz) will produce significantly less lipodystrophy.
I have difficulty in favoring one regimen over an other until a definitive comparative clinical study is done. Both regimens taht you've listed are highly recommened by the recent Department of Health and Human Services (DHHS) guidelines and can be expected to produce excellent clinical results for patients with drug susceptiblbe virus. Combivir-based regimens have been exhaustively studied, with a well-characterized efficacy and tolerability profile. Tenofovir-based regimens appear to have some advantages, namely once-daily dosing and fewer short-term side effects; three year data on Gilead Science's pivotal study (called GS903) have been recently presented at the XV International AIDS Conference in Bangkok and continue to validate the use of tenofovir/3TC/efavirenz. Longer-term data on the safety and "salvagability" are favorable, though some safety data will (as always for any newer drug) require long-term surveillance.
In my practice, I give patients the full set of options and pros and cons. Certainly many patients have elected (with my blessings) to start on tenofovir/3TC/efavirenz. The anticipated availability of the tenofovir/FTC fixed dose combination tablet will further fuel this interest, given the possibility of a two pill, once-daily regimen. Gilead's pledge to not increase the price of the new combination (and nearly 40% reduction in the cost of tenofovir in the developing world)is also noteworthy and welcomed.
Thanks for reading. BY
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