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Continue on monotherapy or switch to combotherapy?
Feb 25, 2001

This forum is wonderful. I really appreciate having it as an information source. I am a 59 year old woman who has been HIV+ since 1982. I was diagnosed in 1991 and my Tcell count was 750. In February 1994 my Tcell count dropped below 500, I was put on AZT, and my Tcell count bounced between 500 and 700 for two years. In November 1995 my doctor suggested stopping AZT because a drug holiday was a new theory at the time and the useful life of AZT was about 17 months. In January 1996 my Tcell count was 250 and I started DDI. Since then my Tcell count has bounced between 500 and 600 and viral load is 0 to a high of 14 with the more sensitive tests. I have no drug side effects and am very healthy. I am a participant in the NIH WHIS study. I don't particularly want to start combo therapy, but my very supportive doctor and WHIS study personnel are unable to give me much info about the long-term consequences of staying on monotherapy. Is anyone else wrestling with this issue?

Response from Dr. Cohen

Thanks for the thanks.

And yes, some are grappling with this.

First, I am making the assumption from your question that your viral load is below detection - either 0 or 14 are below 50 copies if that is what you mean. If instead you mean 140, 1400, or 14 thousand, then what I am about to say would not apply.

The point of treating is to stop HIV from doing damage, and preserve the benefits of treatment for as long as possible. And to use the safest treatments you can to achieve these. And when the viral load is below 50 copies on meds, then it tends to stay there for much longer than when it is above 50 copies. And the immune system can regrow when HIV is this well suppressed.

And if on just one med your viral load is consistently below 50 copies, and you are doing well and feeling well on this medication, then you have a successful treatment.

So, why then don't we currently recommend one drug as an opening move? Well, odds are good that off meds, your viral load would be pretty low as well. I can guess this based on the results from the days when we did give just one antiviral. In general, one med like ddI has just less than a one log drop in viral load. So if your viral load were low to begin with, a simple regimen like this could work for a while, perhaps a good long while. However, if your viral load off meds was higher, say 50 thousand, then on ddI only, or any single med, we did not see prolonged suppression very often - and this led to the use of multiple meds.

But if you are doing well on one, then there is no reason that you have to change. Except for one theoretical one - which is based again on what you mentioned in your question. You mention that your viral load was occasionally measured at a low number. And the concern is that if HIV can grow, then it might create resistance to the one drug you are on. The good news is that this hasn't happened and is unlikely - ddI is one of the meds that HIV has a harder time creating resistance to. But one way to make this simple combo last even longer is to add another med to this combo - which could even more effectively stop it from growing and prolong this regimen that much longer. Of course, more meds, more risk of med side effects... so there is always a balance. But that is where we are in the balance of approaches.

Hope that helps. CC



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