Hi Dr. Pierone, I started treatment early (within 45 days of infection) back on March 5, 2003. Was started on Trizivir/Viramune. Was on that for 15 months until June 2004. My doctor and I decided to go to a once daily regimen and was switched to Truvada/Sustiva. Have been on that since. I am still having sleep issues/crazy dreams (not nightmares just strange & vivid). Have been undectectable since April 2003 on both combos. Last fall after a few months on Truvada/Sustiva I told my doctor the side effects of Sustiva were not subsiding for me. My blood work during both regimens had always been fine, but this paticular time she said my liver enzymes were slightly elevated (80)and that if she were to switch me to something else she would prefer to go to a PI. I didn't want that so I decided to stick with Sustiva. Well here we are in Spring 05, and I still don't feel rested in the mornings. My liver enzymes have been normal since that one reading (and had always been normal before). My question is can I switch back to Viramune. I realize it's a twice a day pill, but am fine with that. Will I have any issues switching back?? Will I have to start with the once a day for 2 weeks and then to twice a day after again?? I'm usually an 8-10 hour a night sleeper so it's really frustrating not get my rest. I have tried Trazadone (made dreams even wackier). Sorry for the long post, just wanted you to have all the pertinent info. CD4's always 600-1000 range, undectable viral load (since April 03), CD4% always in 30-40 range. Thanks for you help. Sleepless in the US

Hello and thanks for posting. There are at least several options.

The first is to simply switch the Sustiva to Viramune. Since you tolerated it before, this should not be a problem even with the current slight increase in liver test results. Although not approved once daily, the pharmacokinetics fully support the use of once daily Viramune and we have hundreds of patients on it as part of once daily therapy with long-term virologic control. If you switch back you can go with once a day for 2 weeks, and then increase to 2 tablets.

Another approach that may work is to lower the dose of Sustiva. There is tremendous variability in blood (and thus brain) levels of this agent. Therapeutic drug monitoring is now available commercially in the U.S. for Sustiva. One approach would be to check a morning (or pre-dose evening) level as a baseline determination. Then reduce the dose to 400mg (2 200mg capsules) and see if the sleep pattern improves. If so, check blood levels after several weeks to make sure they are reasonable.

A third option is to stop therapy altogether and see what happens. I assume that you started therapy for primary HIV infection in the hope that it would favorably modify the course of the disease. Perhaps now is the time to find out if it did. A recent study on treatment of primary HIV infection suggested that unless therapy was commenced within 2 weeks of infection there was little evidence that the subsequent course was impacted.

Thanks for posting and best wishes.