Initiating HIV/AIDS Therapy in Treatment-Naïve Patients How do you deal with toxicities when selecting initial regimens?
	Enlarged Version of Graphics Below	Dr. Wohlfeiler (OC): Toxicity is a very important issue. A good example is if you look at old full dose Norvir. It was an incredibly potent protease inhibitor. But it had too many side effects. And if nobody can take it then it's kind of worthless. So I think side effects are extremely important. And I think that what a patient tolerates really varies a lot from patient to patient. And so I think that that's why you need to really discuss it with the patient. Dr. Kwakwa (OC): I think it's important to do two things up front. The first thing is to review with the patient some of the more common potential side effects of the regimen that they are being started on-certainly not all of the potential side effects, by any means, but some of the more common, immediate side effects that the patient will feel. I find that the patients may not be particularly concerned about an asymptomatic rise in their creatinine, for example, or in their lipids, and so it's very important not only to tell them what to expect, or what to possibly expect, but what to do about each of these issues should they occur, and that one of those things that they do includes to call you, because that gives them some reassurance that they can always call you if there is an issue that requires that they do that. Dr. Wohlfeiler (OC): I will definitely go through the potential side effects with patients and get a sense as to whether or not they think that those are things they are going to be able to cope with, at least over the short term since hopefully most of these are going to be short-term toxicities. I think you definitely have to explore that. Dr. Kwakwa (OC): The other thing that is incredibly important to talk to patients about is the issue of immune reconstitution, to let them know that sometimes, especially for those who come in with very low CD4 counts-that sometimes, some conditions may emerge and become clinically evident when they are on the medication precisely because the medication may be working, and so, let them know about that up front. Otherwise, to have a patient hospitalized with CMV retinitis, or MAC, or PCP after starting antiretroviral therapy is not a fun thing, especially for the patient. It may erode some trust. Dr. Wohlfeiler (OC): I think the key is education. And you really have to take the time, especially when you're initiating antiretroviral therapy, to really talk to your patient, fully inform the patient what he or she is likely to experience because if the patient starts to experience things that they didn't know they might experience, then those are the things that really are scary to patients, make them want to stop a regimen, and also really undermines their confidence in you. The thing I've learned over time is that the quickest way to start off poorly with a patient and have them lose confidence in you from the outset is to subject them to side effects that they weren't expecting, and that they didn't understand might occur on a regimen. So I think it's really important to spend that time and talk to a patient ahead of time about what might happen.
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