Question
Shall we change our combinations and if yes-to what?
9 May 2009. Related: All topics, Changing treatment, Resistance.
What will be the effect if someone who’s on Kaletra and lamivudine two times a day change it to another combination? Is there any chance of resistance in future? The CD4 count at the moment is 255 and VL less than 40. My wife and I live in Thailand where some of the newer drugs are not around, i.e. like Atripla and Truvada, but Truvada is coming next month. I told our ID docotr to change the combination of my wife, but he keeps on talking about future resistance. My combination is Sustiva+tenofovir+lamivudine and despite the Sustiva side effects I am still OK. How many pills do we need in the next combination?
Answer
Firstly, I will try to comment on your combination and then on your wife’s.
Sustiva+lamivudine+tenofovir is a fairly regularly used combination as a first line therapy in the UK. I agree that if Truvada is used, then this is a slight reduction in the pill count as Truvada is one pill (containing tenofovir+FTC). This means that you will have to take 2 pills, once a day. If you think that this will improve your quality of life, then it makes sense to discuss a a possible switch of tenofovir+lamivudine to Truvada with your doctor. If your results are good though and you are happy with your current therapy, then it is fine to stay on it.
The case of your wife is a bit more complicated. From your question, I understand that she is only on Kaletra+lamivudine. If this is the case, then she needs to talk to her doctor for inclusion of one more medication to her combination. For instance tenofovir. In order the treatment to work most effectively, HIV needs to be attacked by a minimum of 3 medications. This is why treatment is also called triple therapy. If your wife does not get one more medicine, then she is at a slightly increased risk of developing resistance to the medicines that she is taking at the moment and this would limit her future treatment options. If your wife has previously used other HIV drugs, this may mean she can not switch to the same drugs as you. If this is her first combination, then as long as her viral load is currently undetectable, she would not get resistance just from the switch.
There is detailed information on treatment (including resistance and how to avoid it) here.
It is good that the doctor has added a 3rd medicine. That is the way it should have been since the very beginning of her treatment.
As for switching from Kaletra to Truvada, it does not make sense. She needs 3 medicines from at least 2 classes. Kaletra and Truvada are from different classes. Truvada+lamivudine only is not a good combination. If Truvada is cheaper that tenofovir+lamivudine, then you can change those two to Truvada, but Kaletra needs to stay.
Finally, if Kaletra is way too expensive for you, you may decide to talk about changing it to possibly efavirenz, perhaps, as that will be cheaper.
Thank you for this infomation, it really helped us. Initially, my wife was prescribed only Kaletra (3 capsules) and lamivudine (one tablet in the morning and same at bed time). Last week, however, I sent her to my ID doctor and he added more medicines (in fact tenofovir, as you predicted). So, how about changeing to Truvada, as the cost of Kaletra in Thailand is very high? In addition, there is that pill burden with Kaletra. Will she develop resistance in future if she change her therapy? Thanks.