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HEPB & HIV - Truvada resistance
May 13, 2011

Over two years ago, I was having problems using Truvada for my HepB & HIV co-infection. A liver biopsy shown no problems with my liver, except for the HepB. Eventually, Hepsera worked to take my HepB viral load down to zero. Then I was put back on Truvada along with Isentress. I've been on that combination before several times, with each time, my alt/ast climbing to the 3k range.

This time, after the Hepsera, my alt & ast have been in the normal range. My cd4 was 230 and now is 569. My hiv viral load went down to under 1k and then went back up to 1k, then 2k and now is at 15k. A recent resistance test shows a mutation to the truvada. I have not missed any dose of the truvada and out of a month, two months ago, I missed one morning of the isentress because I slept through the day. I quickly resolved this. There is an isentress resistance test being performed.

My doctor tells me to keep taking the truvada & isentress, which I am doing. Oh, this last test, showed my alt up 10 points above normal and I am putting this down to something I ate perhaps. Well, I'm hoping.

Is there anything that works, solely for hiv and would allow me to take Hepsera along with hiv meds? I really did wonderful, I think, for my hepb on the Hepsera. I know, going on and off the truvada probably has caused the resistance but the other alternative might have been liver failure and I happen to like the liver I currently have!

Emotionally, I think I'm dealing well with this, except when I think about it. Personally, I don't think truvada and I are friends. It doesn't appear to like me and I tend to want to stay away from such people and meds, though I am continuing on for now. I have lost 'faith' in my two doctors I have seen, but I know, they are not gods and are as human as I am. It concerns me when I'm told truvada is the drug of choice and (to me), it is not the drug of choice for me. Thanks for all the suggestions you may have!

Response from Dr. McGovern

For your hepatitis B, I have to agree that Truvada is an excellent choice. I am not suggesting it is the only consideration for your HIV care, especially not with your rising HIV viral load. However, Truvada is a great drug for HBV since it combines the activity of emtricitabine and tenofovir.

In fact, Hepsera (adefovir) is a weaker cousin of tenofovir. Adefovir is less potent against HBV and is associated with HBV resistance, whereas tenofovir resistance has not been described.

Resistance with HBV is a major problem because this can lead to severe flares of liver function tests.

So if your HBV DNA is suppressed, Truvada may still be a good drug for your liver. It also does not have liver toxicity (such as mitochondrial toxicity).

I would also continue to get serial monitoring of your liver with imaging every six months (eg, Ultrasounds) and alfa feto protein testing.

Your HIV resistance testing will be very helpful. The weak link here will likely be raltegrevir or emtricitabine - much less likely tenofovir....



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