Some things to consider
If possible, don't start HIV therapy unless you are prepared
(and supported) to take your drugs ON time EVERY time;
and do be aware that many side effects get better after the first month
or so. A switch may make you feel better - but, at least to start with,
it could also make you feel worse.
If you are going to change, it must be to a regime that's just as powerful.
Plan for any combo to last three to four years, at least. Decide how radical
you want to be: changing one drug to a closely similar one to avoid one
side effect is less risky; changing everything at once is more so. Ask
for a resistance test on a stored sample of blood if your clinic has one,
as they often do (they can't test you now if you have no detectable HIV).
You must have another viral load test three to four weeks after any change.
If your HIV has 'rebounded', this hopefully won't be long enough for problematic
HIV drug resistance to appear.
To avoid lipoatrophy
For many patients, the facial and limb wasting of lipoatrophy is often
the worst side effect, but is also the most difficult to make switching
recommendations for. No one knows to what extent the different drug classes
and HIV itself contribute to the syndrome. And studies have mainly looked
at whether switching reverses lipoatrophy - when what we're doing is trying
to stop it getting worse.
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Though the evidence is still muddy, d4T keeps coming out tops in the list of NRTIs (nukes) blamed for causing lipoatrophy, as is the duo of d4T and ddI.
The protease inhibitors (PIs) are also implicated. Many doctors suspect that a reinforcing effect between some nukes and the PIs causes the dramatic fat loss some people experience. In general, the better PIs to switch to are the ones also less likely to cause fat accumulation - see next section.
Three studies have documented a very slow, but steady regain in arm/leg fat when patients changed from d4T (or AZT) to abacavir. At the rates observed, reversing lipoatrophy could take
seven years - so it's better to change before it gets bad.
