Treatment Tips : Med Marketplace

Putting together an HIV drug regimen can be an overwhelming experience, especially for those who are newly diagnosed. Derek Thaczuk walks us through key factors to consider when shopping for the treatment combo that will work best for you.

Whether you’re starting HIV treatment for the first time or thinking of switching to new meds, there are a lot of factors to consider. For starters, there are more than two dozen drug options from which to choose. Other important considerations include: efficacy (what regimen is most likely to lower your viral load and
raise your CD4 cell count), drug resistance, dosing, interactions between antiretrovirals (ARVs) and other meds, and side effects.

Reginald Davis of Chicago knows firsthand just how overwhelming selecting an optimal drug combo can be. Soon after he tested positive for HIV in October 2006 at the age of 23, he discovered that his CD4 count was 150 cells, and he found himself under pressure to start ARV treatment ASAP. But before he started popping pills, Davis spent a month considering treatment options and talking about them with his health care provider. He also did lots of reading on his own. “Everyone comes into this, literally, ‘treatment-naive,’” he says. “You don’t know anything about all these treatments when you start.” His doc and health care team encouraged his learning—and his taking the lead in the decision making: “They said, ‘We’re the team looking after you, but the head of that team is you.’”

Given the wide array of effective ARVs now available, people living with HIV can expect their drug combo to meet their individual needs. Because HIV meds are most effective when taken correctly and consistently, finding a regimen that works well with your body and lifestyle is your best bet for optimal adherence and, subsequently, optimal health.

To help you make the best med choices, we’ll start, like Davis did, with the basics. For those taking ARVs for the first time, initial regimens typically draw from three classes: most commonly, two nucleoside reverse transcriptase inhibitors (NRTIs) combined with a powerful representative from either the non-nucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI) families.

Picking the most effective of these drugs is consideration No. 1. The U.S. Department of Health and Human Services’ (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents serves as the go-to source for this decision.

This regularly updated guide pools the latest drug data together, identifying “preferred” drugs based on the results of clinical trials and expert interpretation. All drugs recommended by the DHHS are tried and true in their ability to reduce viral loads and increase CD4 cells.

Two combos currently lead the Guidelines’ NRTI pack, and both are available in fixed-dose combinations that bundle two drugs into one pill: Truvada, containing Viread (tenofovir) and Emtriva (emtricitabine); and Epzicom, containing Ziagen (abacavir) and Epivir (lamivudine).

Of the NNRTIs, Sustiva (efavirenz) is the preferred DHHS option, except for women who are pregnant or trying to conceive, due to the risk for birth defects.
The three top-choice PIs are Kaletra (lopinavir), Lexiva (fosamprenavir) and Reyataz (atazanavir). These PIs usually get a boost from a dose of Norvir (ritonavir)—more on this below.

Even though the Guidelines narrow the list of treatment options down to the most potent drugs, there are still decisions to be made. This means individualizing treatment, based on each HIV-positive person’s specific needs and preferences. Claudia Martorell, MD, MPH, of Tufts University School of Medicine in Boston, says, “Everyone has different priorities. When you treat a patient, you have to know them well and talk about what those priorities are.”