It may be time for a better treatment fit. Grab a handful of straight pins and talk to your tailor, er, doctor about these key issues
If your HIV cocktail is working just fine, thanks, shouldn’t you stick with it? Not necessarily. Having HIV in 2006 doesn’t mean settling for a regimen that runs you ragged with alarm clock reminders, handfuls of pills, weird food restrictions or annoying side effects.
With all the treatment options avail-able now, you have a right to demand more—to expect your combo to evolve along with the science. “I don’t think it is reasonable for someone to stay on a ‘legacy’ prescription when an alternative is available that has evident advantages,” says Graeme Moyle, MD, of Chelsea and Westminster Hospital in London.
The explosion of new studies and data has even health care providers struggling to keep their heads above water. So we’ve boiled it all down to six key questions to ask yourself and discuss with your doctor as you consider making a change.
It’s a Q&A that continues long after the decision itself. “The [new regimen] should be adequately tested to be confident that one is not exchanging one problem for another,” advises Moyle. Either way—and here’s something you may or may not know—you can often go back again to your old combo if you don’t like the new one.
Ask Yourself: How are my numbers? Regardless of which combo you’re on, the primary goal remains the same for most people: Keep your viral load undetectable and your T cells stable or on the rise. If your HIV regimen isn’t doing both, it’s time for a chat with your doctor.
If your HIV has developed resistance to some meds, Moyle says, “The switch may involve replacing a problematic drug.” Finding the right combination of meds could be “a challenge,” Moyle adds, but one that many positive people and their doctors have met.
And most people—even those on meds for a long time—have a good chance of success at keeping their virus in check. “In patients who are receiving just their second or third regimen, I would expect complete viral suppression by 12 weeks,” says Ronald Mitsuyasu, MD, of UCLA’s Center for Clinical AIDS Research and Education in Los Angeles.
If your combo is keeping your virus at bay but you have other reasons for considering a switch, you’re in luck: “Individuals with good viral control are the best switch candidates,” Moyle says.
How’s my adherence? You’ve heard it before: You need to take your HIV meds as prescribed—on time every time—to get the best results. But missing doses is a common problem, studies show—and one that can set the stage for drug resistance. “If a patient really finds it tough to keep up with a regimen, the regimen will eventually fail,” says Michael Saag, MD, of the University of Alabama at Birmingham.
You don’t need to beat yourself up over an occasional slip, but if it happens regularly, discuss the problem with your doctor. Depending on why you’re having trouble sticking to your meds, a more convenient regimen might be just the ticket. “It’s better to nip the problem in the bud and get on something easier,” advises Saag.
Would I do better taking meds less often? We’ve come a long way, baby—from three times a day dosing to twice a day and now sometimes just once. Studies show that for many people, especially first-time combo takers, once-daily regimens are just as effective as twice.
The freedom that comes with having to think about pills only once a day can make for better adherence. But beware: With once-daily meds, adherence is more important than ever, since missing a dose leaves HIV more time to bounce back before the next pill.
Can I take fewer pills? These days, most boosted PIs are dosed at two to six pills a day, while nukes and non-nukes usually involve just one to two pills once or twice a day. If you’re taking more than that, ask your doc if a simpler combo would work for you. Reformulations of old drugs and new fixed-dose combinations—pills containing two or more HIV meds—have improved things further. “I have on occasion asked patients on ‘old’ regimens to consider ‘upgrading’ to fewer regimens that may have less long-term side effects or that require fewer pills or less dosing frequency,” says Mitsuyasu.
Can I drop these side effects? HIV treatment is notorious for its side effects—from the diarrhea, peripheral neuropathy (those painful tingles in the extremities) and anemia associated with the early nukes to the body-shape changes and high blood-fat levels seen with more recent combos. It’s rare for any drug to be completely free of side effects, but we’ve learned to identify—and avoid—some of the worst culprits, such as the nuke Zerit (d4T), which has been linked to lipoatrophy (fat wasting).
There’s much to be said for the “watch and wait” approach—giving new meds a fair shake, since some side effects (especially gastrointestinal symptoms and fatigue) fade as your body adjusts to the new drugs. Mitsuyasu says most side effects should be gone in four to six weeks “or at least [be] reduced in intensity.” Moyle suggests waiting six months before letting side-effect problems force a treatment switch.
Some people add drugs at that point to counteract the side effects. There are some good meds out there for anemia, high cholesterol, diarrhea and so on. But it may also be possible to find an HIV combo that won’t cause those side effects in the first place.
Moyle says the most common side-effects-related switch is from Retrovir (AZT) or Zerit to Epzicom (Epivir plus Ziagen) or Truvada (Emtriva plus Viread) to avoid lipoatrophy and to benefit from the once-daily dosing both those combination pills offer. The second most common change is from Kaletra (lopinavir) to Reyataz (atazanavir) to lessen diarrhea and blood-fat problems; the third most common is away from Sustiva (efavirenz) to manage central nervous system side effects such as depression or strange dreams—although these symptoms may be temporary, too.
What else is in the mix? Here’s another message you may or may not hear frequently: Tell your doctor about everything you are taking. Certain HIV meds interact dangerously with prescription pills, over-the-counter medication, street drugs, herbal remedies or nutritional supplements—decreasing the effectiveness of your meds or even worsening their side effects. Once you list everything you take—and what you want to keep taking—you and your doctor can decide whether a different HIV combo might suit you better.
It sounds like a lot to think about, but when it comes to HIV, having more choices to make means eventually arriving at a more closely tailored fit. Consider what you need most from your meds—and what will keep you loyal to them—and work with your doctor to find a combo that fits.
IS ONCE-DAILY SAFE? In Gilead’s Study 934, more than 500 HIVers new to HIV meds took either once-daily Viread/Emtriva (the drugs in Truvada) or twice- daily Combivir (AZT/Epivir), both with Sustiva. After 48 weeks, 80% in the Viread/Emtriva arm had undetectable viral loads, com---pared with 70% in the Combivir arm. Both regimens worked well suppressing HIV, so how to explain the difference? Answer: More people stopped taking the Combivir combo due to side effects.
CAN I LOSE THE LIPO? Several studies have shown that Reyataz doesn’t boost blood fats like other similar drugs, which may reduce the risk of heart disease. In the SWAN trial, more than 400 HIVers who switched from a boosted PI (in most cases Kaletra) to once-daily Reyataz kept their viral load low—and as a bonus saw their bad LDL cholesterol drop by 12% and their triglycerides fall by 33% after 48 weeks.