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First line treatment
Nov 2, 2000

I am a 39 year old male infected since 3 years and on no meds. My VL went from undetectable (6 months after infection)to currently about 90.000 with a number of 25.000 most of the time. My CD4 during this time was always around 750. (Last count was 90.000 and 900 two months ago).

I feel generally very healthy but had a facial palsy last year (CD4 was 250 before and 1250 after the palsy) and an outbreak of shingles recently. That is why I am thinking about starting medication. Here my question:

What would you recommend as first line treatment in my case? I am a strong believer in immune based therapies and STI's. I have a history of kidney (stones) and liver (enlarged) problems. Nothing major and my liver values are normal.

Thank you very much...

Steve

Response from Dr. Stryker

This is a complicated question, and one that you need to discuss in detail, face to face, with an HIV specialist. Here are my basic thoughts.

One, you are right to be thinking about therapy at this time, given your generally rising viral load, your recent facial palsy, and the fact that your CD4+ count has been as low as 250.

Second, I would generally recommend a combination including a non-nucleoside (viramune or Sustiva) and two nukes. A protease-based regimen is of course possible, but not usually my first choice. Crixivan in particular should probably be avoided, because of the risk of kidney stones, a problem you already face.

Immune-based therapies are in their infancy, so you might consider a clinical trial of this approach, but only as an adjunct/addition to standard therapy. Why? Because they have not been proven to work on their own. IL-2, for instance, may be a very reasonable thing to do in addition to triple-drug therapy, but doesn't treat HIV when used alone.

Finally, regarding STI (strategic treatment interruption), I hate to burst your bubble, but I doubt it would do much in your particular setting. STI may have a role if people are treated very early after HIV infection (though even this is unclear), but in the setting of chronic infection (ie, after three years without any HIV treatment) it doesn't seem to work. Thats what the clinical trials show. This is a premature question for you in any case -- you need to be on treatment first, before there is something to interrupt. Whether or not STI could even be reasonably considered would depend on your response to treatment in the first 6-12 months. Good luck. RAS

Rick Stryker, M.D., M.P.H.



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