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B-Tripla and a Bluey on Bondi Beach

By Bob Frascino, M.D.

April 7, 2011

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Bronzed Aussie Surfer Dude: Howya going mate? Damn you really got chundered by that wave and rip. Hope ya don't mind my sayin' but that surfboard looked about as useful to you as an ashtray on a motorbike.

Dr. Bob: Cough, cough, cough, sputter, cough.

BASD: No worries mate; just keep breathing. She'll be apples.

Dr. Bob: Thanks, cough, cough, and what's that about "apples"?

BASD: That's "strine" (Aussie slang) for "everything will be all right."

Dr. Bob: I know that, you drongo! But how does "she'll be apples" translate into "everything will be all right?"

BASD: No clue, mate. Hey, since you're a bit of the celebrity 'round here. Any chance you'd answer a few medical questions? After you finish coughing up half the ocean, of course! That heaven-on-a-stick spunk of a lifesaver who just pulled you out of the drink suggested I keep you on dry land and away from your surfie mates for a bit. Fair dinkum. That rip looked like it could have tossed you halfway to Tassie (Tasmania).


Note to reader: Before proceeding, I should probably fill you in on what's going on here. I'm on Bondi Beach in Sydney, Australia with some friends (mates). I have just had a rather spectacular wipeout trying to surf. After being gobbled up by the wave and scraped helter-skelter across the ocean floor for a distance that seemed to me to be roughly the size of Manhattan Island, I was grabbed by a buffed smiling Aussie lifesaver (beach lifeguard). He then shouted, "Look out mate! There's a bluey over there. Let's get you outta here." As he cross-chest carried me across the rip, I saw something that looked like a giant blue condom with strings float by.

And now, back to our story ...

Dr. Bob: First, I have a question for you. What in bloody hell is a bluey?

BASD: A bluebottle.

Dr. Bob: A What?

BASD: You yanks call 'em Portuguese Man o' Wars or some such nonsense.

Dr. Bob: Aren't they deadly?

BASD: Well sure, can be, but usually they don't kill you.

Dr. Bob: Usually?

BASD: What are you reading?

Dr. Bob: I'm checking out bluebottles in this book, The Top 100 Most Venomous Creatures in Australia. Looks like the bluey didn't even make the top 100 list.

BASD: Now what are you doing?

Dr. Bob: Cross-checking another source downloaded onto my Kindle, Creatures and Things That Will Maim or Kill You Horribly While Visiting Australia, Volume 17. It says here a bluebottle may look like a jellyfish, but it isn't. Its stinging venom-filled tentacles can paralyze a fish or cause agony to humans. Serious stings cause fever, shock, breathing problems, heart problems and sometimes death. Damn, and it didn't even make it into the top 100 list???

BASD: Let's change the subject mate. Blueies are boring.

Dr. Bob: Boring? I hate to think what you'd find exciting.

BASD: So, here in Oz (Australia), it's been like a century since we've had a new HIV drug. What's up with that?

Dr. Bob: Well, in reality it's been three years since the last new antiretrovirals hit the market. But I agree three years is a bit of a dry spell. The good news is that a new NNRTI is on its way to pharmacy shelves very soon, and there are a few other promising new drugs in phase 2 and 3 development.

BASD: Cool. What's an NNRTI?

Dr. Bob: It's a non-nucleoside reverse transcriptase inhibitor or "non-nuke" for short. Non-nukes block the activity of reverse transcriptase, a critical enzyme in the HIV lifecycle, so that the virus can't convert itself from RNA to DNA. It's the reverse transcriptase-converted DNA that integrates into our DNA in CD4 cells and causes all sorts of havoc.

Non-nukes are often included in first-line combination antiretroviral regimens. Sustiva (efavirenz) has been the preferred non-nuke since it was introduced in 2002. It's one of the three antiretrovirals in Atripla. Viramune (nevirapine) is an alternative non-nuke, but has limitations. Intelence (etravirine) is the new kid on the block in the non-nuke family, but it's used only for HIVers who have resistance or intolerance to other non-nukes.

A new non-nuke, rilpivirine, appears to be on track for approval by the FDA in the States in May. From what I've heard, it will be approved for first-line use, like Sustiva. Ultimately the manufacturer would like to make a co-formulation single tablet of rilpivirine, tenofovir and emtricitabine, but this might take a while, as the FDA has recently asked for longer-term data on the co-formulated pill. The combination would become the second single-tablet, once-daily regimen. (Atripla was the first.) We've nicknamed the new combination "B-tripla!" (A real brand name has not yet been established.)

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See Also
More News & Research on Complera (Rilpivirine/Tenofovir/FTC)

Reader Comments:

Comment by: Bryan (San Francisco) Tue., Aug. 16, 2011 at 3:47 am UTC
Hello Dr. Bob,

I was diagnosed this March with HIV. I was started on Atripla on Aug 2nd, as my first ever treatment and on Aug 8th I started to see the rash. I wasn't able to see my Doc till today Aug 15th. He said my metabolism is probably slow. He has given me 48hrs for the rash to clear or he is switching me to Complera. The rash isn't considered severe because I don't have it in my face, mouth, or eyes. I have the rash from the neck down including some on my hands and feet. It doesn't itch but it does look scary. It's the only side effect I have. Atripla is Ambien as far as I'm concern. I feel like its clearing but it always does until I wake in the morning. Its like ground hog day. Although tonight the rash looks like its healing. My question is, is it to early to switch treatment? Or should I make the switch? I also gotta say that my partner is also on Atripla without any of the side effects. I would also hate to take something different. I know we are not made the same (my partner and I) but if I give Atripla a lil longer maybe I'll do fine. Watcha think Dr. Bob : )
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Comment by: B-Triple Bogey (OnTop DoneUnder) Thu., May. 5, 2011 at 4:26 am UTC
Gore srewth matey, whata pissa. Ya pullin my leg like me old Grandad but he's bin pushin up paper daisys from way back. Reckon ya went spotlighting for emus roosting in tea tree. Either that or ya pukin up some made in China souvenir. Ya sure took the little fella down a peg or 2, hit over the block with ya fine paper. That showed him. But you shoulda cut him some slack cause in Oz geisers that spruik brand names own the filly an have it all tied up.
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Comment by: Poz Oz (Sydney, Australia) Thu., Apr. 21, 2011 at 10:26 pm UTC
Dr Bob,

Not only have you omitted the extensive range of reported and known side effects of this toxic drug (astrocitic migration in the brain causing psychiatric side effects such as fatigue, depression, mania, suicide, hyperlipidaemias, Vitamin D3 hypotvitaminosis and the osteopoenic, immunologic and cognitive issues assoiated with Vitmain D3 hypovitaminosis and assoiation with increased risk of heart attack as well as causing neural tube birth defects in newborns of mothers taking this tetarogenic agent.

Not to mention the requirement to take Efavirenz three hours after food at night to mitigate the psychiatric side effects and related impact on a persons day to day routine, social life and ability to have a spontaneous social life.

Whilst making jokes at the expense of an Australian who possibly saved your life, and alleging that a Bondi Lifesaver is HIV Positive on your possibly Gilead or Merck paid junket to Australia, a country that has lead the international response to the HIV epidemic, you forgot to mention that Efavirenz is an American owned compound, and the related reasons why Efavirenz is prescribed first line in the US, as well as the fact that Efavirenz is the drug most switched from (dumped) by people commencing treatment for the first time.

I refute your claim that Efavirenz has never been bested in clinical trials, it has been shown to be inferior on a number of levels in international studies. You have also failed to declare any interests in Merck or Gilead and I publicly challenge you to deny any financial association.

There are many things that sting in Australia, 'Dr' Bob, none, however, so much as fact in the face of public, obvious and dubiously motivated biased falsification of health information for your own, or others gain.

Please revise your hippocratic oath, especially the part that states 'Do no harm'.
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Replies to this comment:
Comment by: Dr. Bob (San Francisco) Tue., Apr. 26, 2011 at 2:58 pm UTC
Hello Poz Oz,

Generally I tend not to reply to baseless mean-spirited attacks, but yours was rife with so much invective and misinformation that I decided to make an exception. I'll make several points.

1. The point of the blog was not to sing the praises of Efavirenz or Atripla (which I certainly did not), but rather to introduce an entirely new NNRTI that will be a competitor and that, although having certain limitations, has some significant advantages over Efavirenz. (Geez, talk about missing the point!!!!)

2. Had you read my blog more carefully, you would have noted I discussed the well-documented side effect profile of efavirenz, including the CNS effects, increases in cholesterol and triglycerides, the possibly of birth defects, vivid dreams/screaming nightmares, difficulty concentrating, dizziness and drug-drug interactions.

3. There is no "requirement for efavirenz to be taken three hours after food". When starting efavirenz we recommend taking it in the evening on an empty stomach (at least two hours after dinner) to minimize the side effects. This is not a requirement, but merely a suggestion. Most side effects subside within three to four weeks. However, if side effects persist, we recommend a change in therapy.

4. You may attempt to "refute" my claim that efavirenz has never been bested in clinical trials, but in order to do so you'll need evidence of the "international studies" you allude to.

5. You also "challenge" me to deny any financial association with Merck or Gilead and claim I failed to declare any interests in Merck or Gilead. Poz Oz, I categorically deny any financial associate with Merck or Gilead or any other pharmaceutical company. I did not declare any interests in Merck or Gilead because none exist. I also deny your outrageous claim that I provided any "public, obvious and dubiously motivated biased falsification of health information for (my) own or others gain." My "junket to Australia" was not funded by Gilead or Merck or anyone else other than yours truly. I have no idea why you would make such unfounded accusations.

6. Just to set the record straight I should provide a few additional facts. My services here at The Body are provided on a completely voluntary basis. I have been HIV infected since January 1991. I am a board certified clinical immunologist and HIV specialist with over a quarter of a century of experience caring for those infected and affected by HIV/aids. I am the founder and president of The Robert James Frascino AIDS Foundation, whose sole mission is to provide crucial services for men, women and children living with HIV/AIDS worldwide and to raise awareness of the HIV/AIDS epidemic through advocacy and education. To date we have raised over $1,500,000 for AIDS service organizations worldwide.

Finally, I have no cause to revisit my hippocratic oath. It remains intact. You, on the other hand, may want to review basic facts before you begin making accusations. A refresher course from Miss Manners regarding civility would be worthwhile as well.

Poz Oz, might I be so bold as to suggest that the next time you write in you begin with an apology? I also do so hope that if you write in again, your mood ring will be something other than a foul brown color.

Dr. Bob

Comment by: Mike (Washington, DC) Thu., Apr. 14, 2011 at 3:08 pm UTC
Good article. Thanks for the big blue condom in OZ. I see it was so big, you couldn't help but gag!

Returning to my streaming dream now. (yes, you read that correctly)
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Life, Love, Sex, HIV and Other Unscheduled Events

Bob Frascino, M.D., was President and Founder of The Robert James Frascino AIDS Foundation. He had been an outspoken, popular expert in's "Ask the Experts" forums on safe sex and fatigue/anemia since 2000. Once a Fellow of the American Academy of Allergy, Asthma, and Immunology, and the American Academy of Pediatrics, Dr. Frascino served as Associate Clinical Professor of Medicine, Division of Immunology, Rheumatology, and Allergy, at Stanford University Medical Center from 1983 until 2001. He was a member of the American Academy of HIV Medicine and had also been a distinguished member of the executive boards of numerous state and regional associations.

We're inexpressibly saddened to share the news that Dr. Frascino passed away unexpectedly on Saturday, Sept. 17, 2011. Click here to read more and to share your thoughts.

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