Although the official instructions of the use of antiretroviral therapy for HIV infection, every patient is different from the situation, ie the real world the situation is what makes the real instructions.
Nothing written in stone
There are actually a series of formal guidelines for the introduction of first-line antiretroviral treatment (ART) in HIV patients, including the British HIV Association guidelines, WHO guidelines, the guidelines in French, the International AIDS Society guidelines, the Department of Health and Human Services, EU directives clinical AIDS Society ... all have their pros and cons, but are far from everyday practice.
Having treated thousands of patients infected with HIV, I would like to share with you what my first choice for the determinants of ART.
Since I am a counselor at a drug company marketing antiretroviral treatment and receives no money from them, these observations apply only my work and myself. But they have the advantage of being free of any conflict of interest!
These comments do not reflect an institution or group's point of view and is not designed to provide medical advice. I'll answer this one first line in adults and adolescents.
Where to start?
I am completely in line with current guidelines considering the art when CD4 falls below 500/mm3. Historically, lower CD4 count taken into consideration, because the patterns of art were more toxic to limit exposure to the drug. Today, most clinicians agree that we can not wait for the immune system is damaged, since its recovery is of inferior quality.
There is no real urgency to begin antiretroviral therapy. In my opinion it is only necessary that patients are willing to engage. I see only one situation where art is urgent: acute HIV infection with neurological symptoms.
Where to start?
Choosing the backbone of the RTI
In practice, you will need to combine two reverse transcriptase inhibitors (RTI), as "an agent of others." 2RTIs are the backbone of the triple combination of drugs.
Drugs such as ddI, d4T, zidovudine, now discarded, because they are too toxic. In practice, you will need to choose the combination of emtricitabine and tenofovir or abacavir and lamivudine. Both are combinations of solids, ie, they are easy to administer a single pill taken daily. There is not much difference between emtricitabine and lamivudine, for which the choice is mainly between tenofovir and abacavir. Advantages of tenofovir, which is widely accepted, with no functional side effects (no nausea, weakness), and well tolerated. The downside is that you may cause osteopenia in the long term, can be reduced slightly reduced renal function, and demonstrates the low uptake of the central nervous system. Abacavir is the positive side it crosses the blood-brain barrier. The downside of waiting for the results of HLA testing B057 in order to avoid the risk of allergic reaction that is the tolerance of the first generation of NRTIs (fatigue, cytopenias), and three years ago, was suspected to increase cardiovascular risk. Although this was later excluded, remains a very present, the doctors, because the marketing company abacavir could be convincingly its security.
In practice, therefore, more than 2 / 3 the prescription, tenofovir / emtricitabine is the choice of doctor.
The choice of a third agent
This is the dilemma between different government policies. Only with regard to the types of drugs (not the molecules in each class), you can choose between:
* A protease inhibitor (PI)
* A non-nucleoside RT inhibitors (NNRTIs)
* Integrase inhibitor
The boosted PI is the "indulgent" choices, this means that even if patients are not fully compatible they will not select resistant strains rapidly with this treatment. It is a big advantage, especially with a high viral load. The combination of lopinavir and ritonavir has the advantage that the design is the same pill, which is better for compliance. But because of its possible induction of dyslipidemia is the lopinavir / ritonavir is not included in U.S. guidelines as a first choice, although it is in European directives. In our practice, this combination is an important decision and dyslipidemia rarely leads to change. Another interesting option is the darunavir / ritonavir, which has the advantage of a lower incidence of diarrhea with the same force as lopinavir / ritonavir.
I think of atazanavir / ritonavir is not as good as the previous two choices. Although studies show the power, superiority, and that sometimes is not what I see in practice. The main problem with atazanavir / ritonavir in the presence of jaundice in most patients. It 'is often cited as the stigma of HIV infection and undermines social life.
The choice of NNRTI is simple to do. There are mainly two compounds in a competitive market, nevirapine and efavirenz. A third aspect, etravirine, recently on the market but do not fit as it involves side effects and poor intestinal absorption. Nevirapine can cause a severe rash and hepatitis, so its usefulness is limited based on CD4 count. However, it is generally well accepted fabric with proven long-term sustainability. Efavirenz is a potent anti-retroviral drugs, which also gives lasting results. But its introduction is often problematic because of neuropsychiatric side effects like bad dreams, dizziness and vertigo ...
Both nevirapine and efavirenz are not forgiven drugs when they have a low genetic barrier to resistance. When mutations are selected, the class affected.
The combination of tenofovir / emtricitabine / efavirenz exists as a fixed dose (1 tablet per day). It is the first recommended treatment guidelines in the UK. He said that this election was more a financial goal (is the cheapest combo to date) is scientifically ...
The choice is currently only available integrase inhibitor, raltegravir, which the agent is a third option. This has been validated in clinical trials and reported in the U.S. guidelines, but not offered as first choice, but an alternative European Directives and French. Although the short-term safety of this drug is great, as its antiviral activity, it is motivated by two facts. First raltegravir has a low genetic barrier to resistance, which means it is not a forgiving fabric. Then, the cost is higher than for other third-party agents. For example, in France raltegravir only costs the same monthly price (about 750 euros) that the triple combination of tenofovir / emtricitabine / efavirenz. Although clinicians are not economists, it is a real problem when universal access to care is at risk.
Far from the Guide to Real Life
In practice, each patient a new situation. Of course, you must bear in mind that the official guidelines say, but you try to evaluate, at best, what to do with the medications you prescribe. Will it be fully compatible, or will it need a forgiving combo? It is generally difficult to know for 1 or 2 consultations alone. You will also have to sort that potential drug interactions will be problematic if it needs other medications for the coexistence of conditions. There are patients who are better than other gastrointestinal side effects and some patients to see the atazanavir-induced jaundice as a tan a nice holiday ... Nothing is set in stone, really.
