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Risk of increasing HIV resistance to classes of drugs when there is insufficient virus to do a geno or phenotype
Sep 27, 2003

I read much discussion on this forum about starting HAART in rare situations where VL remains undetectable and CD4 counts are normal....but HIV symptoms are bad.

If there is no detectable VL or a very low one, doesn't that mean you cannot do a resistance test to know which drugs the strain of HIV is susceptible to? If so, doesn't that make the choice of the HAART regimen a crapshoot...running the risk of choosing drugs to which the virus is resistant and creating even more resistance? Or would a nondetectable VL for a long while after infection almost ceratinly suggest a weak strain of HIV that would likely be susceptible to all drugs?

How do you choose a regimen that is tolerable, potent and reduces risk of reinforcing drug resistance where genotyping or phenotyping is not possible due to low or nondetectable VL?

Thanks.

Response from Dr. Young

You're correct that if you don't have resistance testing, that you cannot accurately assess the presence of drug resistance.

That said, the risk of drug resistance depends a lot on where you may have acquired HIV, and the prevalence (rates) of resistance in that community. Moreover, if one really knows who they've contracted HIV from, information about their virus or drug regimen can be key in the selection of a drug regimen. (This is what we do for persons who go onto post-exposure prophylactic treatment, like after a needle stick.)

If there is considerable concern about resistance, then avoidance of the kinds of drug resistance patterns can be very important-- since non-nuke resistance is more common than transmitted resistance to boosted protease inhibitors, for example, I might consider using a boosted PI as a component of the starting regimen. Alternatively, certain nucleoside drugs also seem to have less transmitted resistance-- tenofovir or didanosine (ddI) are probably less affected by this phenomena (at least for now).

Hope this helps, BY



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