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Cocktail Conundrums
May 29, 2000

Dear Cal, I am HIV positive for exactly ten years this month. The last two blood tests revealed T-cell counts of 186 and viral load of 12 and then 30 thousand. The T-cell decline has been steady but the viral load has remained under twenty until now. I have decided to begin antiviral treatment and have been given a number of recommendations by various health professionals. 1. Combivir-Sustiva 2. Zerit-Ziagen-Viramune 3. Sustiva-Ziagen-Epivir 4. Combivir-Ziagen-Viramune 5. Combivir-Viramune I have been taking herbs and vitamins regularly for seven years and while I travel extensively for work, I don't expect to have problems with any drug regimen. I have had a mildly irritable bowel since my twenties and it has worsened lately. Otherwise, I am feeling perfectly fine. What do you recommend? Thanks

Response from Dr. Cohen

Well....

First -- glad you decided to start. While there is much that is uncertain about when to start -- it is fair to say that all of us get increasingly nervous when those CD4's go below 200 -- since we know that is the range where nasty illnesses start. And there is still time to recover the cells, with a high chance of success.

As for which combo -- all of those you mention are reasonable. And I can list a few other variations on these themes -- like zerit, epivir, and sustiva... All of these are variations on one nonnuke (viramune vs. sustiva) and two nucleosides. There is no one best combo, and I don't pretend to have the answer as to which one of those you list would be the best -- since each is very likely to work, but each has some small list of potential side effects as well... so there is no one "winner". And what is more -- there is no way to know which one you would feel best on. For example -- some feel fine on Sustiva with no side effects at all, while others find the dizziness pretty distressing. Some get liver irritation on viramune while others don't. That variability in how people respond is why starting a combo, while being actively in touch with whoever you are working with -- is an essential key. Since we can't be sure how you would do -- AND there are substitutions we can make if your first choice isn't working out.

Some fine tuning: one of your combos above (#4) is four meds -- and while that would be more potent -- it is unclear if you need the added potency given your current lab tests. And each med can introduce more potential toxicity -- so I am not sure if you need a four drug combo. Also, #2 uses ziagen before you've taken epivir -- and while you can do this, if you get resistance to the ziagen, you risk losing epivir as well, so some would either use them together or use the epivir first and "save" the ziagen to use second if the epivir combo "fails". And #3 is a newer combo idea with not much info to demonstrate how well it would work -- although it is reasonable to expect it would work fine.

One approach you might consider, depending on where you live -- is to consider a clinical study. We in Boston and many others are doing studies comparing some of the combinations you mention -- and sometimes trying to improve on them as well. Like using these or other meds just once a day.

Whichever you pick -- any of them will work only if you can take them -- each dose, each day. Each is pretty simple -- a small number of meds just twice a day -- but the need to take them is still key.

While I have no "favorite" -- you can have confidence that each should work, and work well. Let us know.

Cal Cohen, M.D., M.S.



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