Ever since the Guidelines came out, many people have thought that they were too aggressive for some patients. The line is too thin if you may have just one key drug in a combination. So I often go straight from two drugs to four, double protease inhibitors and double nucleosides. I feel more comfortable with the margin of error. For many patients the four-drug combination might be a better, more durable therapy than three drugs with only one protease inhibitor.
Some people also add hydroxyurea.
The virologic response seems good. With d4T it has been very difficult to know when or if someone is resistant. One of the strong arguments for starting maximum treatment immediately is that the immune damage is irreversible. I am not sure about that. And for those with CD4 counts over 150, it seems that immune damage is quite reversible.