“It’s time for me to start on the pills. What’s the best drug combination to use first?” This is a question we hear often, and it’s been a puzzlement to doctors and patients alike. Finally, two studies demonstrate that there is actually a best first regimen for most patients just starting treatment: a three-drug combination of AZT, 3TC, and Sustiva.

This combination — also called by their generic or brand names: zidovudine or Retrovir, lamivudine or Epivir, and efavirenz — lasted longer and suppressed HIV better than the other common “drug cocktails” studied.

There were other important advantages: fewer side effects than most combinations and fewer pills to take (two in the morning, one in the evening). It also does not have troublesome food restrictions. Remarkably, it’s one of the least expensive combinations available.

The two studies — funded by the National Institutes of Health and the National Institute of Allergy and Infectious Diseases, not by drug manufacturers — have a lot of research validity: Lots of patients were studied, and the studies were lengthy. (Patients were followed for an average 2.3 years.) For more than 90% of the participants, the combination was still working well after four years.

This writer believes that, despite its cost, resistance testing should still be done before any drug combination is started, to be sure that the patient’s HIV strain will respond well.

Each treatment choice is an individualized decision between physician and patient; one size does not fit all! Because adherence — every pill, on time — is critical to success, frank discussion must ensure that the patient is ready to commit to HIV treatment and to the requirements of a specific regimen.

Of course, as new medications become available, “best choices” will change. However, these new guidelines for initial treatment will help remove some of the guesswork from an important decision.

For details, see The New England Journal of Medicine, Dec. 11, 2003, 349(24): 2293-2315.Sandy Bartlett

Community Education Coordinator, AIDS Services of Austin

This article appears in 2003.

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