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RE: Resistant?
Jul 21, 2003

Dear Dr. Wohl, Thank you so much for answering my question a few days ago regarding my resistance questions. You mentioned that if I were to provide some additional information, then you might be able to give me more specific answers. My viral load was only tested once before I started medications and I have had no holidays. I was diagnosed with PCP (which I how I found out I had AIDS) in 97 with a viral load somewhere around 100k and 20 T cells. Once I started the Viracept, Epivir and Zerit, it did not take long for the VL to become undetectible, but my T cells only arose to around 250-300 where they stayed for several years. Only since I began Trizivir (and then added Viramune), did they go up - to around 350. So, from what you have told me, I can either stay on the Trizivir/Viramune and just make sure the VL doesn't increase and the t cells don't decrease - although I might be risking some additional resistance. Or I could switch to a new cocktail with a PI. If I were your patient, what would you advise me to do? Thank you again for your time - I really appreciate it. Alex

Response from Dr. Wohl

Dear Alex,

Thanks for the additional information. You previously wrote that Trizivir did not keep your viral load undetectable and that your doctor intensified your therapy by adding nevirapine. Subsequent to this manuver, your viral load went from 750 to 253 after a month.

At this point I would get another viral load and a genotype even though your viral load may not be high enough for the lab to do resistance testing. If you still have detectable virus, your choices are what you have stated: stay the course or switch.

If your viral load remains very low but detectable, staying the course may be justified by a) the fact that you may accumulate some more resistance mutations but these will be restricted to the nucleosides and b) that your switch options are limited by your peripheral neuropathy and likely 3TC and non-nucleoside (nevirapine/efavirenz) resistance.

Switching is complicated by the neuropathy and possible non-nucleoside resistance.

However, your previous AIDS history and success on your first regimen, impresses me and I lean toward switching to a regimen that emulates the regimen that worked best for you: a PI and 2 nukes. Your virus is probably not resistant to abacavir or tenofovir or even AZT (ddI is out due to the neuropathy). A combination of a PI plus AZT + tenofovir or abacavir + AZT or tenofovir + abacavir, should work.

The PI can be nelfinavir. Atazanavir, a new PI without nasty lipid effects, is another choice but has an interaction with tenofovir that leads to reduced levels of atazanavir - so I'd avoid it here unless you use AZT + abacavir. The combo of AZT + abacavir + atazanavir (triple A!) might be a great fit for your needs.

It is a tough decision. I'd hedge with another viral load and possibly some help from a genotype if we are lucky and then make the choice. Let us know what happens - DW



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