I have been HIV+ for almost 10 years. Started treatment with viracept, 3tc and d4t for 1-1/2 years in years 6 and 7. For last 2-1/2 years only on 3tc and d4t--removed the viracept due to resistence. I would like to switch off the d4t onto something else to hopefully not further worsen the lipodistrophy I suffer. My cd4 is over 1400 and VL is undect. (hurray!) Please recommend an appropriate substitute and/or other acceptable combined treatment that does not include d4t. Thank you. Fred.

First, I find it remarkable (and great) that you have an undetectable viral load and CD4's of 1400 on only d4T and 3TC. Do you know what your viral load is off treatment? I wonder if you need to be on treatment at all at this point in your disease. In general, I don't strongly advocate stopping therapy that is working, but in your case, you have lipodystrophy without a strong case for a benefit.

As for changing regimens to improve lipodystrophy, the news is not very good. I assume you are talking about facial fat wasting, rather than fat accumulation. If you look across the whole range of studies, it is clear that we don't fully understand the causes of fat wasting. It is likely that there is more than one cause. D4T is associated with lipoatrophy, but so are all of the nucleosides. It appears from some, but not all studies that the risk is highest for d4T, followed by AZT, and lowest for 3TC, with ddI and abacavir in the middle. More importantly, it is not at all clear that changing drugs will improve fat wasting, at least not quickly. In theory, 3TC, abacavir, and ddI might have a lower chance of causing facial thinning, but I am not confident.

I would talk with your doctor about stopping everything for a while, at least to learn where your viral load sits, and to see what your CD4 count will do.

Good luck ATP