selzentry as firstline therapy

[texfire]

Hi guys,

Wondering if anyone has experience using selzentry as first line therapy with some other drugs...a friend is on that and truvada... he started oh 6 months or so ago with truvada and kaletra but stopped that due to side effects.
He has no side effects currently.

I'm recently diagnosed, first cd4 326 so probably will start treatment right away.
Mostly concerned about side effects adn the two that bother me most are anything neurological (my job requires me to be alert at a moments notice and on call 8 days a month for 24 hours)... also the lipoatrophy and cosmetic changes scare my frail self-image.

So, anyways, I'm wondering what makes a drug 'second choice' or for 'treatment experienced' patients. 
I would think it either does not work as well or may have worse side effects..... so is that the case for selzentry?

Thanks,
texfire

[BT65]

Uh, o.k.  What's your viral load and % look like?  You and your doctor will best decide when it's time for you to start meds, and which ones to try.  You would most likely have a resistance test to see what (if anything) the virus is resistant to.

To have a look at the currently-available meds, you might want to check this out:

http://www.aidsmeds.com/list.shtml

[texfire]

Bettytacy,

You didn't answer or comment on any of my questions.
But thanks.

[Assurbanipal]

Hi Texfire

There's some concerns about Selzentry as first line therapy according to the material in the drug summaries on this site:
"Selzentry is not yet approved for people with HIV that have no, or limited, resistance to other available antiretroviral drugs. This includes HIV-positive people beginning treatment for the first time. Preliminary data from a study evaluating the drug in patients new to HIV treatment suggest that Selzentry is somewhat inferior to standard-of-care Sustiva (efavirenz). However, moderate CD4 count and side-effect benefits were found to be associated with the drug, compared to Sustiva." 

And, of course, it isn't effective against all strains of HIV (only CCRC5 sole receptor strains) so you need to see if you have the right type.

Here's the full entry.
http://www.aidsmeds.com/archive/selzentry_1629.shtml

A few, disorganized, thoughts on the rest of your post:

- Generally, from what I can see new drugs tend to be tested first on those who could potentially benefit the most from them, for whom the options used in first line treatment don't work.  Since the trials are an important way to afford access to drugs, this seems a pretty rational method to help those most in need first.  Only later do trials start on treatment naive patients. 

 - More importantly, side effects of a lot of the current first line treatments are quite manageable for the majority of people who take them.  The issues you cite with PI's (lipo etc.) tend to be long term effects and there is hope that newer formulations of PI's will avoid the worst of these longer term effects as well. Selzentry is new (just like the newer formulations of the older drugs)-- thus long term side effects are unlikely to be reported yet -- it doesn't mean equate to long term side effects being likely.

- One of the advantages of the first line treatments is that there is a lot of experience with how they work and how they don't -- that means potential problems are less likely to be lost in the noise.  With the newer treatments, a potential problem may not be recognized as quickly since it does not follow a standard "problem" path.

- If you are interested in using a newer drug as a treatment naive patient, why not do so as part of a trial?  There's likely to be some benefits of increased supervision for you and it increases the benefits for society as a whole.


Hope these ramblings are helpful to you.  Regards
Assurbanipal

 

[texfire]

Hi Texfire
...........
A few, disorganized, thoughts on the rest of your post:

- Generally, from what I can see new drugs tend to be tested first on those who could potentially benefit the most from them, for whom the options used in first line treatment don't work.  Since the trials are an important way to afford access to drugs, this seems a pretty rational method to help those most in need first.  Only later do trials start on treatment naive patients. 

 - More importantly, side effects of a lot of the current first line treatments are quite manageable for the majority of people who take them.  The issues you cite with PI's (lipo etc.) tend to be long term effects and there is hope that newer formulations of PI's will avoid the worst of these longer term effects as well. Selzentry is new (just like the newer formulations of the older drugs)-- thus long term side effects are unlikely to be reported yet -- it doesn't mean equate to long term side effects being likely.

- One of the advantages of the first line treatments is that there is a lot of experience with how they work and how they don't -- that means potential problems are less likely to be lost in the noise.  With the newer treatments, a potential problem may not be recognized as quickly since it does not follow a standard "problem" path.

- If you are interested in using a newer drug as a treatment naive patient, why not do so as part of a trial?  There's likely to be some benefits of increased supervision for you and it increases the benefits for society as a whole.

Hope these ramblings are helpful to you.  Regards
Assurbanipal

Hey there,

thanks for the respsonse..very good things to think about...
- As for new meds in treatment naive people...  Wouldn't you suppose (and I think it's true) that when a new disease is discovered and medicine is developed for it, then the newer meds are less 'refined' for treatment of that disease.  They may have less efficacy, more (or more serious) side effects or some other deficiencies.  And as time goes on, meds are refined for better potency or less side effects.  So, after some 20 years of med development, a new patient comes into it.  Why shouldn't he start on the best known therapy? 
So, for HIV, I think that very close to what's happening.  I don't know that anyone would start AZT as their primary drug.  But the newest drugs, why not?  Why aren't docs doing new drug studies simultaneously on treatment naive people along with treatment experienced people?  There may be, but you see plenty of recommendations for new drugs for experienced people only, not naive people. 

One reasonable explanation may be that if that new great drug generally has resistance developed to it in 5 years, then maybe a naive person should wait to use it until it is 'really needed'.  That's a line my doc is taking.  But I'm not clear it's been shown that the is better for a patient... To try to illustrate what I'm thinking.. presume we look at health (as a %) over 8 years... case 1 is started on established therapy, case 2 on brand new therapy which will eventually proven to be better clinically than case 1 therapy (though not known yet).  If case 1 goes down 10% a year and then at 40% starts the new drug, it goes up 10%.  Case 2 starts on new drug and has half the rate of decline of health of the 1st drug.
case 1: 100 - 90- 80- 70- 60- 50 - 40 - 50 - 60
case 2 : 100 - 95- 90- 85- 80- 75- 70- 65-60
This is way speculative of course, but over those years, case 2 has a generally higher level of health than having substandard therapy and 'recovering' once you reach a low point. 
Oh, I don't know that I've explained it so well.... nevertheless....

Perhaps they are for treatment experienced only because they are know to be less effective?  Is this the case?  Best meds failed you, so try these even though we know they are not as good, or perhaps have worse side effects.

Gosh, I've confused myself now thinking in circles.
----
My doc is one that believes in monotherapy with protease inhibitors, as seen here...
http://www.poz.com/articles/hiv_monotherapy_kaletra_761_14295.shtml  Actually, he's the first doc mentioned in that article.....

So, now I've been thinking a bit about monotherapy.
It seems clear that a lower percentage of people on monotherapy get undetected VL's.
But, it's probably safe to say that they have less side effects.  And develop less resistance to available drug options.
And what if I'm a lucky one that does get undectable VL's?  Even the study showed that 2/3rds of people on monotherapy did.
Why is it not reasonable to start on monotherapy with frequent labs to see which group you are in..responsive or not?


OK, well, I'm off to do more research...
Thanks for the response..

texfire

[newt]

Believing and looking at a decent study are two different things. Many docs used to to believe in AZT monotherapy.

PI monotherpay may be good for a large proportion of people, but it aint good for as many as a PI / NNRTI  + 2 nukes.

A more reasonable approach is to start on 3 drugs and reduce to 1 when viral load is undetectable. Indeed, this is the subject of a big study starting soon on the UK.  I hope the outcome is favourable, but I will wait and see.

In the end, people make their own choices on treatment. At present, standard of care for 1st time therapy is 3 active drugs from 2 classes for good reasons. Cos it works. Belt and braces like.

- matt

[texfire]

Believing and looking at a decent study are two different things. Many docs used to to believe in AZT monotherapy.

PI monotherpay may be good for a large proportion of people, but it aint good for as many as a PI / NNRTI  + 2 nukes.

A more reasonable approach is to start on 3 drugs and reduce to 1 when viral load is undetectable. Indeed, this is the subject of a big study starting soon on the UK.  I hope the outcome is favourable, but I will wait and see.

In the end, people make their own choices on treatment. At present, standard of care for 1st time therapy is 3 active drugs from 2 classes for good reasons. Cos it works. Belt and braces like.

- matt

Great quick response..
Well, I can say that he believes in it because he does the studies... nevertheless..
though I grant you the point that 3 > 1, it is still the fact that the study showed that 2/3rds of pts had the desired result.
And I think that was only 8% less than triple therapy.
So, choosing which to start is a question of is that 8% increase (if the study findings are the truth) worth the possible increased side effects, possible increased resistance to RTI's, increased cost and increased pill burden.
Why wouldn't it be better (for people with cd4's in 300's) to start with minimal therapy, see if it works with regular blood checks, and then up the therapy 33% of the time when it doesn't?  It's not like I'm at a risk for AIDS at cd4 of 326, so I don't know I need to go all out.  I've always been a minimalist when it comes to medications though, so maybe that's why I think this way.

No?

[Assurbanipal]

Hi again Texfire

If I understand your basic point correctly it is that starting today, with enough CD 4 cells to protect you from an OI in the near term, there are enough drugs and you have enough time that you can experiment with minimal therapies in hopes of minimal side effects -- always having the option of HAART in the background.

I think a fundamental message, that for someone starting treatment today there are a lot of options and you should choose ones that give you the best quality of life, is one that you can read into a lot of the sciience and into many of the postings on these boards. 

But I think there's a few other messages as well that you might want to consider.

1) What we think we know about how drug resistance develops is that it is a process of evolutionary mutation -- the more drugs in your system, the more mutations have to occur in the virus to succeed in reproducing around the drugs  And the more copies of the virus floating around and reproducing, the more mutation opportunities.  Thus Newt points out that monotherapy might be less likely to lead to resistance if you start it when you've already knocked the virus down to very low levels.  (That appears to be suggested in the article as well -- showing it was largely successful when it succeeded in knocking down virus levels quickly.)

2) Are you banking too much on  the idea that there was only an 8% difference in result?  Its always very tempting to read one of these studies and to see a number and assume that it is the number.  But the studies are typically quite small and all the write-up really said was that 8% was significant -- in other words that one can say with (95%?, 99%?) confidence that Kaletra/Combivir is better than Kaletra alone.  With only 136 enrolled in the study, you can't really assume that the true difference in results is 8% (which was probably about 5-6 people in this study).  Instead you need to think of it as some range in your head (say 5% to 15%, or 1% to 25%) Would saaying it that way change the way you feel about the option?


You know, I was thinking about you this past week and wondering if I made the case strong enough for doing "unusual" first line therapies as part of a trial.  Presumably if there's a bunch of folks all in the same new potential treatment, common problems will pop out in a way that might not be spotted in a "one-off" which is one of the potential benefits for you as an individual.

Well, I hope the above hasn't come across wrong -- I get the sense that you are chewing around on possible options in your head and welcome other arguments and points of view at this point. But n the end you need to be comfortable with what you choose to start and what your options are to continue / change.  You've got some time to mull things over and get comfortable. 

Wishing you the best

A 

[trellium]

Why wouldn't it be better (for people with cd4's in 300's) to start with minimal therapy, see if it works with regular blood checks, and then up the therapy 33% of the time when it doesn't?  It's not like I'm at a risk for AIDS at cd4 of 326, so I don't know I need to go all out.  I've always been a minimalist when it comes to medications though, so maybe that's why I think this way.

No?

Durability.  You want a potent drug combo that can suppress viral replication for as long as possible with the least side effects.
If you are thinking of going monotherapy with a boosted PI, it is better to start off with a combo of 3 active drugs to get viral load down to undetectable level (constant <50) for 24 weeks before starting monotherapy.  Most Kaletra monotherapy and induction-maintenance trials I read have this criteria of VL <50 minimum for 24 weeks before making the switch.
 
Starting off with "minimal therapy" is akin to sequential monotherapy which has shown to be less durable & inferior during the pre-HAART era.  Once you developed resistance to a single drug (which can happen quickly with monotherapy), that drug (and perhaps other drugs in the same class depending on the resistance profile) will be pretty much useless.  There are only 5 classes of limited drugs available currently, its not like we have an endless stock pile of different active meds to trial by error if 1 fails after another to get that perfect minimalist mix.
 
Durable or minimal? 
Sometimes less is just not enough 
The final choice is really up to you.

[Miss Philicia]

Starting off with "minimal therapy" is akin to sequential monotherapy which has shown to be less durable & inferior during the pre-HAART era. 

Agreed.  If you wish to be drug resistant to most HIV meds, then knock yourself out.  As someone here who suffered through the mess that was mono/dual therapies in the 90's and is currently possessing a complicated resistance profile, I must ponder why a newly diagnosed person here feels the need to reinvent the wheel during their first month of HIV.

[texfire]

Assurbanipal,

You are correct in the thought that I'm not in near proximity to an AIDS defining illness and so there's no need to start aggressive treatment to stop that from happening.  I am concerned about side effects primarily because of what I do for a living and my doc has ruled out sustiva as an option due to its neurological side effects (though I don't suffer from any diagnosed mental illness )  Nevertheless, I would like to use the most minimal, yet effective, strategy at this point.

Unfortunately for this board, my doc wants to wait 3 months and repeat my labs before I start therapy.  This gives me plenty of time to stew over all the options and throw ideas out there.  However outlandish to some establishment people they may be.
Of course a spherical earth was outlandish at one point in time.

I also totally grant you your point about that one particular study and it's 8% finding.  No, we don't know if it's the 'truth' per se.  I think it is unlikely to be really 60%, and hell, if could even be a smaller difference.  But anyways, it looks at populations as a whole and my body may not read the same physiology text as everyone elses and may react far better or worse than 'typical'.

As for mutations and resistance, I think you are right in the general mechanism. I  need to look into resistance acquired to kaletra monotherapy and the rates at which it occurs (I think i saw it somewhere).  And does that then infer resistance to the other PI's like reyataz?  Worst case scenario (I guess someone will dream up something worse).. I do kaletra monotherapy.  3 or 6 or whatever months later my VL hasn't moved.  Now I'm resistant to kaletra.  Can I use another PI?  Or, do I go to combo with NNRTI's and NRTI's..which is just as recommended as a course with a PI.  Then I'm on that course for however long.  Then I can try a fusion inhibitor or integrase inhibitor.. I don't know...

And none of your posts come across as wrong.  I prefer a very direct, practical (though respectful) approach in discussion (like you are doing)..why beat around the bush?  I can take it

Trellium,

My doc would only advocate monotherapy with kaletra at this point.  So, if that failed, then I'd go on to a multi-drug regimen.  So, it's not endless monotherapy....unlike my love-sex life (which was a series of serial monogamy.)
Though ending up at monotherapy seems like a reasonable option.  My doc has concern about side effects of NRTI's related to heart and bone health...so that's why he favors monotherapy sometimes.  I would imagine though that those are longer term problems rather than after just a year of therapy..though I also think we really don't know that either.

Philly267,

Are you really equating initiating treatment in 2008 with initiating treatment in the 90's?  I'm sorry but AZT monotherapy, followed by multiple other old med monotherapy is not what I'm talking about.  The newer drugs are more specific and believed to have far less side effects than what you had to choose from.  Don't be hatin on me because treatment choice is something I want to discuss.  I find it funny really.. in so so so so many threads, people bash their doctor and say you have to question what they say and remain vigilant.  And here, you act as if I'm supposed to stick my nose in the ass of the lemming ahead of me.  I'm just looking to evaluate other ways down the cliff.

texfire

[Miss Philicia]

Are you really equating initiating treatment in 2008 with initiating treatment in the 90's? 

Nope.  I'm saying monotherapy is still monotherapy, regardless of the med.  Having been on all of those old meds, and currently on all of the latest meds which won't even be offered to you as first line treatment presently, I think I speak with slightly more authority than you can imagine, certainly in terms of comparing side effects.

But feel free to play Junior Scientist.  It's one thing to be vigilant, it's entirely different to be naive.  No need to be so defensive.  It's not like this is the first time someone has attempted to do what you posting in their first month of diagnosis.  I fully expect you will change your tune about this issue.

[texfire]

Philly,

Can you be more condescending? 

I'm aware of what monotherapy is.  You have no idea what will be offered to me.  In fact, I could write my own prescriptions and pay cash for a drug if I wanted to.  I do not question whatever authority you bring to the situation and you shouldn't do so about me.  This junior scientist is actually an MD, though in an area quite different than infectious disease.  I'm not naive.  I'm challenging/questioning the guidelines.  I'm only 'defensive' in my posts to you because I find your posts high and mighty and condescending to me.  You can see that I've not responded 'defensively' to the thoughtful posts of terllium and assurbanipal even though they advocate concern about initial monotherapy as well.  I would think you would understand my interests in limiting side-effects if you have been so ravaged by them.

Lastly, I hope you know that there is the world of academia, where us docs talk about what we believe to be right and wrong.  Then there's what we tell the patients (or the media).  That incorporates a (frequently false) belief of decreased intellect on the patient's part along with concern of potential public health ramifications of said discussions.  For example, the proclamation by swiss researchers that you can't transmit HIV given a set of circumstances.  Those crazy europeans right?

texfire

[BT65]

Texfire, what kind of an M.D. are you and where did you get your medical doctorate from?

[texfire]

Bettytacy,

I'm not into posting something publicly that would make it able to know who I am.  I can tell you I went to medical school in the United States and trained in emergency medicine.
If there's a specific reason you need more detail, feel free to PM me...

texfire

[thunter34]

Bettytacy,

I'm not into posting something publicly that would make it able to know who I am.  I can tell you I went to medical school in the United States and trained in emergency medicine.
If there's a specific reason you need more detail, feel free to PM me...

texfire

You're the one who has been condescending from where I'm sitting, texfire.  Don't see how telling what kind of M.D. you are or where you got your medical doctorate from would magically reveal your identity...unless you happen to be the sole recipient of some mail order degree from one of those knock off TV universities.

[texfire]

thunter,

I wish getting an MD was that easy.  Instead, I did 9 years of training after college.
Nevertheless, I did say what I do.  I'm not going to say where specifically.  This has more to do with the fact that some think that an HIV + doctor shouldn't be practicing.  And yes, if my colleagues came across this board, saw what I did specifically and where I did it, they would know it was me.  I was told in another thread to watch who I disclose my status to.
I didn't say where I went to school, other than a standard medical school in the states. I was told my school was in the top 10 in the last US News and World reports magazine. However, they aren't that different from each other.  Your ability to be a good/smart/whatever doc is more a function of your effort than the school you attended. 
Nevertheless, I'm sorry if I offended you thunter34, that was not my intent.  I was offended by two specific posts, neither of which were yours.

Anyways, the whole point was, since I'm not that sick right now, a major priority is to avoid deleterious side effects while still being effective.  And I personally may be willing to take a less effective therapy if I know that side effects are less.

junior scientist texfire
...who is wondering why where he went to school and what he specifically does professionally is relevant to a discussion of what treatment might be best for him taking into account effectiveness, tolerability and long term side effects....

[thunter34]

...who is wondering why where he went to school and what he specifically does professionally is relevant to a discussion of what treatment might be best for him taking into account effectiveness, tolerability and long term side effects....

Well, I suppose mainly because of statements like these:

You have no idea what will be offered to me.  In fact, I could write my own prescriptions and pay cash for a drug if I wanted to.

Well, smell you, Nancy Drew.  Good for you that you could write your own prescriptions and pay cash for your drugs.  Still, not every drug should be readily within your reach no matter what kind of doctor you say you are simply because of where these particular meds are in the pipeline.  I guess what's gotten the attention on your MD background is this air of "know-it-all-ness" in your responses to people like philly...who really is NOT talking out of his ass about all of this. 

I'm not naive....It's not like I'm at a risk for AIDS at cd4 of 326, so I don't know I need to go all out. 

That attitude IS naive.  You are not as far from AIDS as you seem to think - 126 off by the best count, and CD4 readings can vary +/- about 50 per take, so you may not even be that far.  Certainly not far enough to be so cavalier in your approach you meds.

[newt]

If you want to do Kaletra (or another PI) monotherapy for your first line treatment then do it. If you don't go undetectable in a few weeks then you can add in 2 nukes.  The risk of PI resistance is low...but is is there.

The data is plain to read - in all studies bar the latest one, everyone on 3 drugs got better results than on Kaletra alone. They's all quite small studies. They show nothing other than an interesting approach that may work for a fair number of people.

Kaletra monotherapy from the start is not an outlandish idea. But it is unproven. I think 3 drugs to start and perhaps reduce later a better strategy. This is also unproven, hence the UK study (in which I intend to enrol, with some degree of nervousness).

I know people doing well on PI monotherapy but I also know people where it hasn't worked. I certainly wouldn't do it from day 1 if I had a viral load of 100.00+

In the end it's your call.

- matt

[texfire]

Hey newt...

thanks for the response.. yea, we're thinking along the same lines.  It's a hard decision to make, but whether I do triple therapy and try to wean, or single therapy and up it if I fail....I think they are both reasonable choices given what is important to me particularly.  And despite what you may take from my postings, probably triple with quick reduction to single therapy is what I'm thinking currently.  But as I have 2+ months before I even get retested to start labs.... who knows, maybe I'll look into kaleta plus selzentry or some other atypical first choice.  But you are right, it's my choice.  I can make it, given all information and advice I can find.... I really do appreciate it.

What I have yet to appreciate is thunter34...
So, thunter... you are offended or think I'm pompous because I correct the other fellow who says that he's on medicines I won't even be offered?  Who is he to even know such a thing?  The simple fact is that I have access to whatever FDA approved meds are in existence.  Even if my insurance doesn't want to pay it.  And if that upsets you, it's your problem, not mine.

I have not had a 'know it all attidude' as you say in regards to HIV therapy.  If I knew for sure what I wanted to do, I wouldn't have posted here. Anyways, neither of you have even budged from 'standard of care'.  Can you not realize that first of all, they are guidelines.  Not rules.  Not absolutes.  Not best for everybody.  I'm looking for peoples experiences/thoughts on non-standard therapy, hence the title of this whole posting.  And he comes along and calls me a junior scientist for exploring these ideas (which are not new and are the subject of new research).. well he can f** off as far as I'm concerned.  He is the one acting all high and mighty/all-knowing one in my observation.  You say he's not talking out of his ass.. well, where did I say he was?  And then I'm debased by you because I wont' tell you what medical school I went to?  Whatever... I thought this would be an accepting community. Did I call you names?  Did I say you were stupid?  No.  But you, so clever, surmise that I got an MD degree from a TV university.  Which if you are so stupid as to think that is even a possibility...I can't even help you.  Whatever, clearly the forum mimics a gay bar, and you are the typical cynical quipping fag in the corner shadows.  Now I'm calling you names.

And, as for my progression to AIDS, though I'm thrilled that you seem to hope I get it sooner rather than later...
If you are up to facing accepted statistics,  on page 61 of the DHHS guidelines for use of antiretroviral agents in HIV 1 infected adults and adolescents, you will notice I have between a 3.0 and 4.1% risk of developing AIDS in the next 6 months.  And if you consult page 106 of the same guidelines, you will see I have a less than 2% chance of developing AIDS in the next 3 years in the HAART era (if I  take HAART meds).  I'd take these numbers and say that it is highly unlikely that AIDS will be in my immediate future anytime soon. 

Clearly, you and the other fellow have derailed, and caused me to derail, the purpose of this thread.  It's not terribly productive to even continue on from here on out.  I guess I"ll respond only to non-insulting posts unless I'm feeling a need to wallow in the mud with the bovine who called me to their pen. 

As far as I'm concerned, the thread can be erased.

texfire

[thunter34]

Whatever, clearly the forum mimics a gay bar, and you are the typical cynical quipping fag in the corner shadows.  Now I'm calling you names.

And, as for my progression to AIDS, though I'm thrilled that you seem to hope I get it sooner rather than later...

Listen here, you:  I never, ever said I hoped you got AIDS sooner rather than later.  Never - not ever.  I said that you aren't as far off from that end of the spectrum as you seem to think you are, meaning that you don't have have much room to play around with your medications and risk potential resistance.  But, as with your other previous posts, you've plowed right past any good intentions and moved right on to the hateful, condescending retort. 

Clearly some serious anger management issues.  And as for the "fag" name calling...well, I think that speaks for itself.

Newt is right:  It's your call.  Do whatever the fuck you want to.  Swig down "whatever FDA approved meds are in existence" with abandon in whatever half-assed regimen scheme you concoct.  Best o' luck to ya.

[texfire]

See,

That's the problem.  Reading comprehension is apparently difficult for some.  Let me just rehash to help...
-I said "you seem to hope".  I did not say you said.  That's how it came across to me.  Perhaps you didn't mean it that way.
-I didn't even get into my job/income/insurance until someone told me what I couldn't do and didn't have access to.
-I have not plowed right past any good intentions.  If you had comprehended the thread in its entirety, you would see that I'd had a civil discussion with more than one person until it was derailed....and for that I'm just as at fault as I said before.
however, thunter, your posts have not had anything of good intention aside from the good reminder that a single blood test is a moment in time and may be off from the real truth.  Instead you enter the thread telling me I'm condescending, expressing complete confusion over why someone on an HIV forum might choose to not say what he does specifically (even if he is working where he trained and has the only job of its kind in the city, so naming it clearly names me), and then asks if I got a degree from a TV university.  So, let me summarize..your entire first post came across as insulting to me and I responded in a very civil way and apologized if you personally were offended.  So, what do you do?  Let's see....."smell you, nancy drew". That's productive.  You continue to ignore my question of what my career has to do with the choice of what meds I take.  You then call me naive and cavalier.  Both of which I also find offensive.  So, I took my time to appropriately respond to newt (who has been respectful to me) and then to respond to you (in a disrespectful manner since you had shown me the same).  And I'm the problem?  Are you appointed as the verbal attack dog for philly or something?  Guess I didn't know what I stepped in on this forum. 
-And I shouldn't call you a fag in the mean way or perhaps not even in the nice way since we don't know each other.  I let your insulting posts anger me. I thought this was an inclusive forum for throwing ideas about.  It comes across to me that I'm getting a bunch of shit for being a doctor and making money..which I didn't even bring up until someone has the gall to tell me what I do and don't have access to.
-You are right... it's my call as for the meds I want to take.  I believe my physician knows far more about HIV and its therapy than you do.  Than I do.  What you call cavalier may be cutting edge, or it may be wrong.  But you have to take what evidence there is.  If I don't take NRTI's and you do, I guess in 10-20 years we'll see who had worse heart and bone disease.  Problem is, we don't know it now.  And nothing I've talked about is, as you say, half-assed.  There are studies performed and underway looking at what I'm talking about.  You may not inherently believe them to be rational choices, but that's your belief and not necessarily the truth.  I don't even know why you are posting here.  Other than the comment about my CD4 count, you've added not one iota of productive thought to the purpose of this thread and instead chosen to bash me.  I may fight back, but I don't go in places looking for fights like it appears you did here.

texfire

[Peter Staley]

Texfire & Tim (thunter):

Please stop this little flame war now.  Consider yourselves warned.  We'll issue "time-outs" if you both keep this up.

Texfire -- use of the slur "fag" in these forums, unless you are one yourself ("So us fags had a FABULOUS time last night!"), can quickly lead to being banned.

Peter Staley
Founder & Advisory Editor
AIDSmeds.com