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My Doctors's Strategy for Ov
Jan 26, 2002

Hey Doctor: I see someone who is considered a top hematologist in NYC. He claims there are no "experts" in HIV and treatment because everyone is so different. His treatment of me has impressed me and makes me also wonder considering it goes against many of the theories of how meds work and do not work. Here has been my trend: 12/99- VL 120,640 T cells 226 (started Viracept and Combivir) 3/00- VL zero T cells 262 6/00- VL zero T cells 338 9/00- VL 770 T cells 410 1/01- VL 1000 T cells- 360 4/01- VL 2411 T cells 286 7/01- VL 7300 T cells 475 11/01- VL 12900 T cells 325 My doctor waits 6 weeks now to mintor since my VL has gone up for over 1.5 years if maybe I need a switch. 1/02- VL from 12900 down to 10,000 and T cells from 325 up to 445. I know most doctors feel the minute you are undetectable that you switch drugs. My doctor believes I still get benefits from my drugs and that I should ride out a cocktail that has NO SIDE EFFECTS for as long as possible before switching. Up to now he fels I have no real huge leeps in my VL nor have I clinically done any worse than over 2 years ago even with the viral load going up. Now it seems it even dropped this past visit. He believes quality of life and your own body and how you look and your trend has a lot to do with how he treats. To save options he feels is better especially when he feels I am doing VERY well. Sorry this is so long but wwnated to share my story.

Jason- 28

Response from Dr. Young

Thank you for your question.

I have to differ (strongly) with some of the advice that your doctor has given you.

Firstly, there are quite a number of very reputable HIV doctors in the city of New York. Many of the most respected HIV treatment opinion leaders work in the city. To think that there are not respectable HIV physicians is ignorant and is not good advice.

In reviewing your labs, it is clear that you have had an ever increasing viral load increase over the past years; such rise is often accompanied by increasing degrees of resistance to your current medications, and much more ominously, cross resistance to other HIV medications. The continuation of medications in this setting is contrary to managment guidelines published by the National Institute of Health, Deparment of Health and Human Services, the Henry Kaiser Institute and the American Academy of HIV Medicine. I would respectfully advise your doctor to consider these position guidelines in making your treatment decisions.

The correct response in managing persons like you takes into account what your available treatment options are. In past years, a sentiment to avoid rapid use of available medications made sense, since we had only a handful of medications to prescribe. In 2002, we have accumulated a robust set of information about how to manage and monitor patients, in order to maximize down-stream treatment options and further ensure the maximum likelihood of subsequent treatment success.

The correct response to a viral load increase is not to switch medications at the moment of first detectable viral load, but to analyze the situation, assess for possible reasons for viral breakthrough-- these reasons include, but are not limited to viral resistance.

The philosophy to ride out the cocktail as long as possible has some inherent risk-- particularly the genesis of highly cross resistant virus. The goal of achieving a side effect free regimen is important, but not unachievable with other regimens. Using this as the sole basis for not entertaining a treatment switch is incorrect and ignorant of much recent well controlled, and well designed clinical trials.

I'd certainly suggest a second option with another doctor in your city. Hope this is helpful, keep asking questions; and certainly feel free to contact us at this forum in the future. BY



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