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VL 150K! Start therapy? Baseline resistance
May 31, 2004

Dear doc,

I have been infected for a year and havent been on therapy yet. My VL has been consistently high (150K) since my first tests. My CD4 is 430 and based on this my doctor has delayed therapy (apparently this is the new approach in europe). My concern is that these guidelines in europe might safeguard the financial interests of the governments that have to pay for the drugs and might want to delay therapy as much as possible and that with such a high VL I might be undermining my inmune system, undergoing brain damage, etc... What is your outlook on this issue? Also, I was infected with a virus with PI mutations 82 and 90 and therefore very PI resistant but no loss of sensitivity to any other drugs. Should I delay therapy as much as possible? Thank you very much for your invaluable help. Grateful European

Response from Dr. Young

Thank you for your question and comments.

You raise an interesting point about how the cost of medications might affect the recommendations about when and where to start ARVs. Certainly, in some countries where access to care is severely compromised by budgetary constraints, there will be incentive to wait as long as possible, in order to make drugs available to more (with lower CD4s).

In your particular instance, were you my patient in the US, I probably would not recommend starting therapy, so long as you were asymptomatic and feeling well. A single viral load determinate of 150K needs to be corroborated by other tests before assuming that you have a "high" viral load; there's plenty of new data on new treatment regimens that show that high viral load patients can respond equivalently well to HAART as lower viral load patients. A CD4 count of 430 is well within the normal range in our diagnostic labs, so the trends in your CD4 counts might be helpful in making prognostic claims about when to start on medications. The fact that you acquired protease inhibitor resistant virus is significant, and severely limits some of your potential treatment options, though I'd point out that merely having a mutations 82 and 90 does not prove that all current PIs won't work (this is where many of us Yankee doctors obtain a phenotypic resistance test). Nevertheless, delaying therapy for a while makes long-term strategic sense to me, since I believe strongly that in the future (maybe near-term) we'll see improved medications for persons with PI-resistance.

I hope this opinion is helpful to you, let us know how you're doing from time to time. BY



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