Choosing Your First Regimen
April 25, 2004
Choice is good, right? Definitely! But it can be confusing. Especially if you've decided to get started with HIV treatment and you're trying to pick a first regimen. The goals of HIV treatment are to get the amount of HIV in your blood (viral load) as low as possible and keep it down for as long as possible, to improve your immune system by increasing your disease-fighting CD4 cells, to reduce illness and to improve your quality of life.
There are guidelines to help you and your doctor choose your first treatment regimen. If you take a peek at the guidelines you'll see that there are lots of drugs that are effective but only certain drug combinations are listed as "Preferred Regimens," while others are listed as "Alternative Regimens." So how do you make a choice?
Your first treatment regimen will probably contain a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI) along with two nucleoside reverse transcriptase inhibitors (NRTIs). This combination will attack HIV at different parts of its life cycle to pack a strong punch against the virus.
The PIs listed in the guidelines as "Preferred" or "Alternative" are probably about the same in terms of how effective they are against HIV. (The PI Kaletra probably reaches the highest anti-HIV levels in the blood.)
Possible long-term side effects of all PIs are changes in the location of fat on your body (fat redistribution), high blood fat levels, changes in the way your body processes sugar (insulin resistance) and kidney stones (with Crixivan). You may also experience changes in liver function tests or inflammation of the liver (hepatitis). All PIs may cause stomach upset (nausea, vomiting, diarrhea, stomach pain, gas) or a rash. Patients on Norvir may have tingling or numbness in the mouth.
Sustiva is an NNRTI that is "Preferred." Another NNRTI, Viramune, is often used to treat HIV and is listed in the "Alternatives" category. Studies have shown that Sustiva is as effective against HIV as the PIs. Regimens with NNRTIs are considered more "patient-friendly" than regimens with PIs. NNRTIs generally have easier dosing schedules and, usually, fewer side effects than PIs. One possible long-term side effect of NNRTIs is liver damage.
In the short term, Sustiva can cause rash, drowsiness, insomnia, central nervous system side effects (confusion, inability to concentrate, dizziness, vivid dreams), stomach upset (nausea, stomach pain) and fever. Sustiva should not be taken by women who are pregnant or considering getting pregnant because it may cause birth defects.
The most common side effect of Viramune is skin rash. In a small number of people, the rash can be serious. Another potential side effect is hepatitis, especially in women (including pregnant women) with CD4 cell counts greater than 250 or men with CD4 cell counts greater than 400 at the time of starting Viramune. People taking Viramune should have frequent liver tests and doctor visits, especially during the first 18 weeks of treatment.
A final consideration when comparing NNRTIs with PIs is that only one mutation in the genetic material of HIV causes drug resistance to NNRTIs. And not just the NNRTI you're taking; resistance wipes out the entire class of drugs. With PIs, the development of resistance is a multi-step process. Also, if you are resistant to one PI you may not be resistant to the entire class.
There are lots of drugs that work well against HIV. So when you and your doctor talk about a treatment regimen, think about what will work well for you and your lifestyle. Think about the dose schedule and the number of pills, think about side effects and think about resistance. There is no first regimen that is best for everyone, but there are ways of finding out what might be the best one for you!
The guidelines are available at: http://aidsinfo.nih.gov/guidelines/.
Anne Monroe is a medical student with a longstanding interest in HIV clinical trials.
This article was provided by PositiveWords.