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PI Sparing
Sep 1, 2000

I just tested positive for HIV. My bloodwork showed a CD4 count of 183 and a viral load of 18,000. My physician (the only one in my area with any experience with HIV treatment) immediately began to prescribe a protease inhibitor with two nukes. From what I have read, PI's require more pills and have more side effects. In addition resistance to one often confers resistance to all. I don't have any symptoms at this point (with the slight possibility of minor fatigue). So, I asked why not start with a non-nuke and two nukes combination which would be less pills, less side effects, and keep PIs as a later treatment option. He immediately said okay, without any hesitation, and changed the prescription. This shocked me and made me feel less confident in his judgment. I have started taking Abacavir, Epivir, and Sustiva. Should I be concerned about this doctor's lack of dedication to the original prescription?

Response from Dr. Pavia

I don't think you should be concerned about his lake of rigidity. In fact, it reflects that state of the art. Starting with non nukes or starting with PI's are both acceptable options, both according to the guidelines and to "expert opinion" (whatever that is). Obviously, if you make PI's you feel the balance is more in one direction than if you make a non nuke. Each has advantages and disadvantages, and I think the most important thing is to match the drug to the patient.

Here's a quick take. PI's have the advantage of a high genetic barrier to resistance, the longest track record, evidence that virus that becomes resistant may not be as bad for you, and good evidence showing that it knocks out virus in many compartments. Down sides are the number of pills (not as bad as it once was), problems with cross resistance (also a problem for non nukes), more tendency to increase blood sugar and (maybe) a greater risk of lipodystrophy.

Non nukes have lower pill burdens, can be take once a day (although only sustiva is approved for once a day), are generally easier to tolerate after the first month, and do not induce PI resistance. But, the disadvantages are an easier path to resistance, nasty rashes for some people, interesting neurologic side effects for some people on Sustiva, and cross resistance between all of the non nukes. All of these balance out to some degree. The one concern that may be really important is that the non nukes have been extremely important when added to PI's in so called salvage regimens.

Bottom line. Both approaches are good. Your regimen is a very good and potent one. IF it works for you, you are comfortable with the schedule, the side effects and the pills, you should do very well. Your doctor listened to you, which is a very good sign, rather than saying "I am the doctor, just do what I say, chump"

Good luck


Andrew T. Pavia, M.D.


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