If you’re just starting treatment...

The old guide sized up each med for mixing and matching; now, “the cocktails, not the individual drugs, are evaluated,” explains POZ medical advisor David Gelman, MD. The feds recommend two combos: non-nuke Sustiva + 3TC + (AZT or d4T or Viread), and protease inhibitor Kaletra + 2 nukes (3TC, AZT or d4T). This contradicts British HIV Association guidelines, which reject starting with too-toxic d4T (see “London Calling,” POZ, September 2003).

Now emphasizing individualized therapy, the guidelines OK triple-nuke combo 3TC + Ziagen + (AZT or d4T) only if your viral load is under 100,000, and nix Sustiva or a ddI + d4T combo if you’re preggers or planning to be.

If you’ve been around the treatment block...
What’s new for oldies? A detailed definition of “treatment failure” along with advice on picking new meds after a combo flops:
1. Try switching combos or adding drugs from new classes (like entry inhibitors) to perk up a pooped regimen.
2. Use resistance testing to guide new drug choices.
3. Don’t use blood drug-level monitoring (“therapeutic drug monitoring”)—it’s not clear it helps.
4. Add a PI booster to ratchet up the power of your combo. “Avoid STIs,” the guidelines say, echoing past versions.

If you think this all sounds old hat...
Join the club. “Guidelines by their very nature are conservative— behind the curve of clinical knowledge once they come out,” Gelman says, noting that newcomers PI Reyataz and nuke Emtriva are barely mentioned. What they do offer is backup for docs to make your insurance cover that slightly off-beat combo.

“Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” can be yours. Call: 800.448.0440. Write: AIDS INFO, P.O. Box 6303, Rockville, MD 20849. Surf: www.aidsinfo.nih.gov/guidelines/