When Should I Start Treatment, and What Should I Take First? en español
Okay, I'm ready to start therapy. What should I take?
The U.S. Department of Health and Human Services (DHHS) guidelines are quite strict about which drugs HIV-infected people should start with. If the point of therapy is to decrease viral load to the lowest possible level—"undetectable" as determined by viral load testing—for as long as possible, the most effective drugs must be used to achieve this. Simply put, the most effective anti-HIV drugs should be used in combination with each other to ensure that maximum pressure is being placed on the virus.
An anti-HIV drug regimen should consist of at least three drugs, usually from at least two classes of anti-HIV drugs. For an explanation of how each class of anti-HIV drugs stops the virus from replicating, click on the following lesson link:
The following table is based on the most recent version of the DHHS guidelines, last updated in November 2008.
"Preferred" or "Alternative" Regimens for HIV-Positive People Beginning HIV Treatment for the First Time
For HIV-positive people starting HIV treatment for the first time, a typical regimen contains one non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs), OR a protease inhibitor (PI) plus two NRTIs. The DHHS has designated some HIV drugs "preferred" options, based on study results indicating powerful and long-lasting effectiveness, acceptable tolerability, and ease of use. "Alternative" HIV drug options are those that have been proven useful in clinical trials, but may have disadvantages—such as less effectiveness or more side effects—compared to preferred options.
People with moderate to severe liver disease (Child-Pugh score B or C) should not use.
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Women with a CD4 count greater than 250 and men with a CD4 count greater than 400 before starting treatment should not use Viramune.
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Early treatment failure has been documented in people who combined Viramune with the NRTIs Truvada (tenofovir plus emtricitabine in one tablet); Viread (tenofovir) + Emtriva (emtricitabine) or Viread + Epviir (lamivudine). These should be used with caution if combined with Viramune.
*People combining Sustiva with Truvada may take the fixed-dose three-in-one tablet Atripla.
PI Options:
Recommendation:
PI:
When to avoid or use with caution:
Preferred**:
Once-dailyReyataz (atazanavir) plus Norvir (ritonavir)
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People on high dose proton pump inhibitors (PPIs) for acid reflux, equivalent to more than 20 mg of Prilosec (omeprazole), should not use Reyataz/Norvir.
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People taking lower dose PPIs, H2 blockers and antacids for acid reflux should use Reyataz/Norvir with caution.
Once-daily Kaletra may cause more diarrhea than twice-daily Kaletra and may be less effective in people starting treatment with viral loads greater than 100,000.
People who test positive for HLA-B*5701, a genetic mutation that greatly increases the risk of a serious allergic reaction to abacavir, should not use abacavir.
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People at high risk for cardiovascular disease should use abacavir with caution, as they may be at greater risk of heart attacks.
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People who start treatment with viral loads greater than 100,000 should use abacavir with caution, as they may be at greater risk of early treatment failure.
HIV drug regimens that should NOT be taken at ANY time
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Any anti-HIV drug taken alone (called "monotherapy"). However, Retrovir (AZT) alone may be considered in pregnant women with low viral load (less than 1,000) to help prevent transmission of HIV to their child.
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Two NRTI (Nucleoside Reverse Transcriptase Inhibitors) drugs only. However, if a patient is currently on a 2-NRTI drug regimen, it is reasonable to continue if their viral load is being suppressed.
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Regimens that contain only three NRTIs, with the exception of Trizivir (zidovudine/lamivudine/abacavir) and possibly Viread (tenofovir) + Retrovir (zidovudine) + Epivir (lamivudine) in people who cannot tolerate other regimens.
Specific HIV drugs that should NOT be taken at ANY time
Sustiva (efavirenz) during 1st trimester of pregnancy or women who might become pregnant, except when no other options are available and potential benefits outweigh the risks.
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Viracept (nelfinavir) during any stage of pregnancy.
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Videx (ddI) + Zerit (d4T), except when no other options are available, and potential benefits outweigh the risks
While the DHHS guidelines seem very specific and overwhelming, the experts responsible for making these recommendations stress a very important point: that selecting a drug regimen should be based on an HIV-positive person's individual needs. In other words, an HIV-positive person may have specific needs with respect to a drug combination's effectiveness (perhaps against drug-resistant virus), side effects (some people may be more sensitive to certain adverse effects than others), drug interactions (some HIV drugs are difficult to combine with other medications HIV-positive people take), and other infections or illnesses (people with hepatitis B or hepatitis C may need to be treated with certain HIV drugs very carefully).
The DHHS also recommends the use of drug-resistance testing to help figure out which anti-HIV drugs should be used as first-time treatment. This is because some people are infected with drug-resistant strains of HIV that may limit certain anti-HIV drug treatment options, even in people starting treatment for the first time. To learn more about HIV drug resistance and drug-resistance testing, click here:
Above all, it is important that you take the correct dose of your medications every time you're supposed to take them, exactly as prescribed by your health care provider or recommended by your pharamcist. This is called treatment adherence—you need to take your medications correctly if they are to keep you healthy. To learn more about treatment adherence, click here:
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