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Choose HIV Drugs That Work for You

By Frank Pizzoli

December 2003

Choose HIV Drugs That Work for You

Ever hit a restaurant with a menu bigger than your apartment? You need food, but the choices are staggering. HIV drugs are similar. Current information empowers consumers to make "informed" choices when choosing HIV drugs.

Know Your Goal

HIV treatment's ultimate goal is to preserve infection-fighting CD4 cells by lowering your viral load (VL) to an "undetectable" level for as long as possible. Ideally, you want your VL to remain undetectable, which means there are fewer than 50 virions (particles of the virus) per millimeter of blood -- the lowest amount blood tests can measure. Below 50, fewer CD4 cells are being attacked by the virus than if VL is higher. Protecting CD4 cells from viral attack is paramount because they fight off nasty, sometimes life-threatening, infections.

Know Your Choices

When choosing HIV drug combinations remember it's one thing to initially achieve lower VL. It's another to sustain that lowering over time. Although most combinations initially lower VL, some drugs are simply better at keeping VL lower for longer periods of time.

Here's shorthand for the five different HIV drug classes from which "combinations" are selected: two types of "nukes" (nucleoside and nucleotide reverse transcriptase inhibitors), "non-nukes" (non-nucleoside reverse transcriptase inhibitors), protease inhibitors, and fusion inhibitors. Combinations should include at least three different drugs. For initial therapy, the Federal Government recommends certain "preferred" drugs for a combination of either two nukes plus a protease inhibitor or two nukes plus a non-nuke.

In chart form, you'd see 23 choices of medicine made from 19 different compounds. (The additional choices are actually combinations of two or three of the 19 compounds. Although there are 23 meds, the number of effective combinations that you can choose is limited. Therefore, you'll want to choose drugs that will not only reach your goal of undetectable as fast as possible, but that will keep HIV as low as possible for as long as possible. That's also exactly what the new Federal Guidelines stress: "Treatment goals should be maximal and durable suppression of viral load."

Drug Interactions

In addition to how well and for how long a combination keeps viral load undetectable, you'll want to consider possible side effects and drug interactions. Because of the way some drugs interact with others, certain HIV drugs should never be taken together. In fact, you should make sure your doctor knows everything you're taking, including vitamins and recreational drugs. Interactions are a big deal.

As far as side effects, all HIV drugs can cause them. But the fewer and milder the side effects, the better. Keep in mind that this is a very individual thing. Side effects vary from drug to drug, and even among different individuals taking the same drug. So consider your lifestyle. For example, if you have a job where you have to be mentally alert, drugs that make it hard to concentrate may not be right for you.


To lower the number of pills taken daily, called "pill burden," there are HIV meds that combine two or three drugs into one pill. This can make adherence more convenient. So can combinations that are taken fewer times during the day. Although dosing convenience is a nice quality in a drug combination -- especially once-a-day convenience -- it isn't the best or only reason to choose one drug over another. "Convenience" doesn't automatically make a regimen effective at keeping VL low for as long as possible. The true measure of success is how long your VL stays undetectable. In fact, recent Federal Government Guidelines noted a major concern about once-daily therapy over "the paucity (lack of) of long-term trials with comparison to potent twice daily regimens."

There are also the issues of food requirements. Some HIV drugs have food requirements which means they are taken with or without food, or with particular types of food. Some drugs have easier food rules than others. For example, some nukes have no food restrictions, but others must be taken with meals. Non-nuke drugs have no restrictions. And depending on the drug, protease inhibitors are taken with or without food. Some HIV drugs have no food restrictions and are taken at meal time, almost like a built in reminder when to take them. But having to take one drug with food and another without food can be a hassle. With or without food requirements, the main goal is to pick drugs that will keep your VL as low as possible for as long as possible.

Adherence and Resistance

All medicines work to some degree, but only if you take them. Remember being warned to finish all your antibiotics because stopping prematurely allows the rash to return? Same result with HIV drugs, only it's called "resistance."

Resistance to your HIV meds means your drugs can no longer fight off the virus. This can happen if the HIV virus evolves in such a way that it enables new copies of itself to survive in the presence of the drugs you're taking. Missing doses can result in the amount of medicine in your blood dropping below levels needed to control the virus. Uncontrolled, the virus will then be free to invade infection-fighting CD4 cells. As more and more CD4 cells are destroyed, you are much more likely to develop opportunistic infections. This "chain reaction" concerns the Federal Government, which notes that "missing one [once-daily] dose may result in inadequate drug exposure over a defined period of time leading to a higher probability of development of drug resistance."

To avoid resistance, research indicates HIV drugs must be taken 95 percent of the time. Even if taken 95 percent of the time, some people still develop resistance. And even with less than perfect adherence, resistance doesn't always develop. The point is that some HIV drugs are "more forgiving" and others "less forgiving" if you miss doses. Try to pick drugs with a good track record at keeping HIV undetectable and avoiding resistance.


Whether you're starting HIV therapy for the first time or switching regimens, it's important to choose drug combinations that keep your VL undetectable for as long as possible. And that's regardless of the number of pills required on a daily basis. Of all the factors you'll consider, remember that there's no relationship between the "convenience" of taking fewer pills and their "effectiveness." The fact of the matter is that some drugs are simply better at keeping VL undetectable for the long haul. And of these drugs, there are options. Don't trade off "today convenience" for "tomorrow's effectiveness."

Frank Pizzoli writes frequently for Body Positive, and also contributes to Instinct, POZ, and New York Blade News. He founded the non-profit Positive Opportunities (, which offers educational seminars and benefits counseling to HIV-infected people through support from Broadway Cares/Equity Fights AIDS and the Greater Harrisburg Foundation.

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