When to start the medications is also a topic of much discussion and controversy. Before the development of protease inhibitors, initiation of antiretroviral medications was considered when the T-helper-cell count fell below 500. Use of medications was not recommended earlier in the course of the infection for fear that once they were necessary (when the T-helper-cell count began to fall and the consequent risk of opportunistic infections began to rise), they might no longer be effective. AZT, ddl, and ddC, when used as monotherapy, often become ineffective after six to twelve months because of the development of resistance. Combination therapy offers longer suppression of the virus and can decrease the likelihood that resistance will develop. Combining 3TC with AZT will prevent resistance to the AZT from developing, so that combination is now preferred over the use of either drug alone. The protease inhibitors are even more effective in combination with the anti-retrovirals in maintaining T-cell count and decreasing viral load. The use of two antiretrovirals with a protease inhibitor (a strategy called triple therapy) has also been tried, and it is now the preferred regimen for many patients because of its increased effectiveness.


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