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 following table is based on the most recent version of the DHHS guidelines, last updated in October 2011.
"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, OR an integrase inhibitor 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, and "Acceptable" treatment options, which can be used in certain circumstanced, but are not judged to be equal to preferred or alternative regimens.
Women in the first trimester of pregnancy or likely to become pregnant should not use Sustiva.
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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.
Complera or other Edurant-based regimens should be used cautiously by people living with HIV with viral loads in excess of 100,000 copies.
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Complera or Edurant should not be taken if proton pump inhibitors (PPIs) for acid reflux are also being used.
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People who test positive for HLA-B*5701, a genetic mutation that greatly increases the risk of a serious allergic reaction to Ziagen, should not use Ziagen.
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People at high risk for cardiovascular disease should use Epzicom 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 Epzicom with caution, as they may be at greater risk of early treatment failure.
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Once daily Kaletra is not recommended for pregnant women
Acceptable Regimens [and Acceptable Regimens but More Definitive Data are Needed]
Viramune should not be used in people with moderate to severe liver disease (Child-Pugh score B or C)
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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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Viramune and the abacavir in Epzicom can both cause hypersensitivity (allergic) reactions. They should be used together with caution.
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The zidovudine in Combivir can affect the bone marrow's ability to produce new red and white blood cells. It can also cause fat loss in the face and limbs (lipoatrophy) and, rarely, a buildup of lactic acid in the blood and fatty liver disease.
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Kaletra plus Combivir is the preferred regimen for pregnant women.
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Norvir-boosted Reyataz is preferred over unboosted Reyataz, but can be used when Norvir boosting is not possible.
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Tropism testing is required before Selzentry can be used. Only people who's virus uses only the CCR5 coreceptor on CD4 cells will benefit from Selzentry.
Regimens that may be acceptable but shoud be used with caution
Invirase (saquinavir) + low-dose Norvir (ritonavir) and Epzicom (abacavir + lamivudine) orCombivir (zidovudine + lamivudine) [More definitive data needed.]
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Norvir-boosted Invirase was linked to abnormal heart rhythms is a study of HIV-negative volunteers. Heart testing (electrocardiograms) should be conducted before starting Norvir-boosted Invirase; the drug is not recommended for people with certain heart rhythm abnormalities.
Specific drugs that should NOT be taken when starting therapy for the first time
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 (zidovudine) 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
Viramune (nevirapine) in women starting therapy for the first time with CD4 cells greater than 250 or men starting therapy for the first time with CD4s greater than 400.
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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Videx (didanosine) + Zerit (stavudine), 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 pharmacist. 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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