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starting new treatment as you adviced but confused about genotype results
May 11, 2005

i wrote to you when my cd4's were down to 189 and your advice was to see a compassionate (thanks for the big tip) expert. just got both phenotype and genotype results and my "expert" says the results are useless since i was NOT taking any medication at the time the blood was drawn (i've been "off the pill" since mid-2002) is this so? then the resistance it shows is not a guideline for the prescription? i am utterly confused. from 1996 to 1998 i took crixivan, ddi and 3tc, undetectable load and reasonable cd4's but i was literally wasting again with the side-effects (from 208 lbs to 147, i'm 6'2, 57 yrs old) so i discontinued and felt better. 1st "vacation" of less than a year, then second "cocktail" of zerit, 3tc and rescriptor from late 1999 to mid-2002. side-effects were tolerable but i was forced to discontinue treatment because pfzier withdrew it from the mexican market (rescriptor worked for me but was not profitable to them). genotypes were made at that date and kaletra, zerit and ddi was the suggested prescription. i did not take it. cd4's had been in the mid to high 300's viral load relatively stable at 2 to 3,000 with or without the medication. decided to "take a vacation" again (my quality of life was superb, as was my general health and aspect) monitoring cd4's every six months, while following immune-boosting treatments in an alternative clinic. from 2002 until 2005. cd's below 200 for the first time and i wrote to you. three weeks ago it was down to 119, genotypes and fenotypes were made and while the results came i spent three weeks in the hospital with iv nutrition and treatment of severe candidiasis and molluskum contagiosum (disgusting, and in the WORST place possible, of course) and a through auscultation and check-up. cd4's are up to 179 now. are the genotype and phenotype results that arrived today really not valid to consider in what i am prescribed? anyway, he suggests kaletra and trizivir and was reasonably frank about the possible side-effects but obsessed with an undetectable viral load as a goal. i'm willing to start but the genotype results issue makes me distrustful in general. what do YOU think? thank you

Response from Dr. Frascino

Hi,

Ideally what you want is an HIV specialist who is both compassionate and competent.

Regarding resistance testing, it is true having the tests performed while you are still taking antiretroviral medications is preferable and could provide additional information. Since you have been off meds since 2002, this was not an option; however, that does not mean the results you got are useless!! The resistance shown on your recent tests is indeed valid and should definitely be taken into consideration as you decide on your next HAART regimen.

What your doctor was referring to is the possibility that your virus may change somewhat off meds. We call this reverting back to wild type. Non-dominate subtypes of virus may not be present in large enough quantities to show up on resistance profiling when you are off meds. However, that does not mean you should not have had the tests performed! At this point, you need all the information obtainable to help guide your next treatment decision. So if your resistance test shows some resistance to certain medications, those medications (and others to which your virus may be cross resistant) should definitely not be included in your next regimen. Your past treatment history also needs to be taken into consideration so that you can avoid drugs that were not well tolerated or to which you previously demonstrated resistance. In addition, there are also certain drug combinations that you should steer clear of if at all possible. For instance, you mention Kaletra, Zerit and ddI as a suggested combination. Zerit and ddI should not be used in combination due to overlapping toxicities.

Your specialist suggested Kaletra plus Trizivir. However, you've been on 3TC in the past. If you have 3TC resistance (referred to as "M184"), this may not be the wisest choice for you. Other options are certainly available and might be more desirable for a variety of reasons. It appears that you have never been on a non-nucleoside reverse transcriptase inhibitor. Consequently, Sustiva is a possibility. Also, as far as fixed-dose combination drugs with fewer potential side effects than Trizivir, I would suggest Truvada (FTC plus Viread).

Finally, if you don't feel your current "expert" is a good fit for you, consider getting a second opinion from another HIV specialist.

Good luck!

Dr. Bob


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