Initiating HIV/AIDS Therapy in Treatment-Naïve Patients What are the advantages of using PI-based regimens?
	Enlarged Version of Graphics Below	Dr. Bellos (OC): The advantages for the PI-based regimens are obviously, the potency. That's not saying that non-nucleoside-based regimens are not potent, and I think that that is really an individual clinician's decision in terms of initial or presenting viral load and T-cell count. Dr. Bellos (VO): Obviously, if you have a patient that has a very high viral load-let's say over a half a million-and a T-cell count of less than 20, that's a patient that you're going to want to give a regimen to, or to design a regimen for, that will have the most potency up front, and in that setting, in my opinion, one would lean more towards a protease-based regimen. The resistance threshold for protease-based regimens is also much higher than it would be for a non-nucleoside-based regimen, considering that there is essentially one mutation that can cause you to lose the entire class for the nucleosides, whereas most of the protease inhibitors require multiple mutations in order to significantly decrease efficacy. In that setting with that patient-again, with the high viral load, lower T-cell count, I would lean more toward a protease-based regimen than a non-nucleoside-based regimen.   See Slide Dr. Bellos (OC): In the patient, for example, who has a moderately elevated viral load-100,000, 150,000-with a T-cell count of above 200, or around 250, that's a patient who will tolerate and do very well with a non-nucleoside-based regimen. Dr. Wohlfeiler (OC): I actually like PI based regimens. I had gotten away from PIs for a period of time. And I've really come back into the PI fold. I like the fact that for the most part resistance is more difficult to develop and it usually requires multiple mutations, as opposed to the nonnucs, which have a lower genetic barrier. And now that we've got better PIs that have less toxicity and are easier to take, I think that they really become much more patient friendly. So I tend to like the PIs that are newer. And the ones that I probably use the most are fosamprenavir and atazanavir. Dr. Wohlfeiler (VO): And of those two, the thing that I've found to be problematic in my practice is the problem with the interaction between atazanavir and proton pump inhibitors because I would say that at any given time in my practice I can have as many as 60% to 80% of patients who are having GI problems that they might at least intermittently take PPIs for. And so that has been a problem with atazanavir. So luckily that issue was studied with fosamprenavir and was not an issue. So I know I can safely use those PPIs with fosamprenavir.   See Slide Dr. Kwakwa (OC): Well, for example, with atazanavir, there is an interaction with tenofovir that requires a dose adjustment of the atazanavir. With, also, lopinavir/ritonavir, there is an interaction with tenofovir that really doesn't require a dose adjustment, but then changes levels, and perhaps changes influx and efflux of tenofovir that may be of concern.
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