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Recent infection with resistant virus... SCARED!!
Jan 30, 2004

Dear Dr.

I was infected this past may. My last numbers were VL 160K and CD4 350. My genotype had the following resistance mutations: Protease: L10V, K20R, M36I, L63P, A71V, V82A, L90M; Reverse Transcriptase: V118I. I am really concerned because by what I have read on the net it seems that my virus is resistant to all PIs!! 1) Is that so? What about new PIs like atazanavir? What about NRTIs and NNRTIs? 2) Judging by my blood numbers and genotype, should I delay starting therapy as much as possible since I do not seem to have many options left or should I start asap to try and get it under control? 3) I had heard that mutated virus was less virulent but I was infected 7 months ago and already my numbers are worrying!! How can that be? 4) I have heard Drs. say that now adays you can expect to live normal life spans with HIV infection... does that apply to my case too or would it depend more on scientific progress and new drugs? It was hard enough to know that i was HIV +, but when I had finally dealt with it I am told that my virus is very resistant to a lot of meds!! 5) Will I ever get to undetectable? I am soooo scared!

Thank you... I am aware that my question is long and probably complicated...

Grateful spaniard.

Response from Dr. Lee

It is a problem that you have a virus that seems to have so many PI mutations that confer resistance (especially the L90 & V82), but there may still be PI's that can be utilized to treat your infection. Also, because the RT genome has only one (not highly significant) mutation, you have several non-PI options.

The primary mutations of concern for the newer PI's appear to be: I54, or V32 with I46 for Lexiva, or the I50 for Reyataz. I would suggest that if you utilize one of these PI's they should be dosed with boosting from Norivir. (Let's not get into the politics of this, the science is what we are discussing.)

You may also consider utilizing a nonnucleoside reverse transcriptase inhibitor instead of a PI. There are several combinations using Efavirenz(Sustiva)or Nevirapine (Virammune)that have been shown to be very effective.

If you were infected recently, your T4 (CD4) lymphocytes may as yet not have recovered from the initial infection. It seems that the virus is most effective at killing T cells in the early infections and in the very late infections when the immune system is otherwise either not "revved" up to fight or has been damaged beyond having the capacity to fight. So, your level may not be as low if you re-check it later.

But you need to decide soon about treatment. I usually go with: "when in doubt- treat." However, it is most important that you get with an HIV-treater that you trust and work out the details with them. If you decide to treat, I would suggest rechecking the genotype fairly soon and very close following of the viral loads.

I would like to reassure you that there are many options remaining for you. It is very likely that you will be able to get the virus under control and even get it to undetectable.



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