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stubborn numbers
Aug 2, 2006

Hi there Doctors,

Thanks for your responses to everyone - all the info here is amazingly helpful for all of us!

I've been positive since Jan 2001, and have been on meds since April 2002. I've been on viracept+combivir. That failed when I developed resistance to AZT so my doctor switched me to kaletra+emtriva+zerit. I've really struggled with side effects, and last year, had a nasty bout of PCP - I'm currently on dapsone too. Apart from that, my health has been generally ok.

Problem is, despite different regimens, my CD4s have gone from 211 to 310, and back down to 165, and my viral load has never been below 90,000, and is currently 290,000. I am genuinely adherent - I have only ever missed two doses in 4 years as i honesty feel that I really must take my meds extremely seriously, especially when so many do not have access to them; so I am really a bit confused as to why things don't really seem to be working. I have developed AIDS within 5 years of my diagnosis, despite treatment.

Do you have any suggestions? Are there any more effective regimens than mine? Would switching from a PI-based regimen to an NNRTI one be worth considering?

Thank you for your time, and for all you do both here and in your professions.

Puzzled

Response from Dr. Young

Dear Puzzled-

Thanks for your post and kind words.

I'm quite concerned about your history-

Your current viral load (and adherence) is almost certainly indicative of treatment failure and additional drug resistance. Treatment failure easily explains the ominous decline in your CD4 count. Part of my concern stems from the selection of d4T (Zerit) following the know presence of AZT (Retrovir, Combivir) resistance-- the two drugs have highly similar resistance patterns and resistance to AZT usually begets (and predicts) d4T resistance; similarly, resistance to 3TC (Epivir, Combivir) confers resistance to FTC (Emtriva).

It's possible that your previous regimen failure also presaged the emergence of PI cross resistance, first to nelfinavir (Viracept) and later to lopinavir/ritoanvir (Kaletra).

The best way to sort these issues out (and to ascertain your next regimen) is to obtain resistance testing now (while your still taking your current regimen). If you were my patient, I'd want to see both a genotype and phenotypic test-- sooner, rather than later; since procrastinating could increase the risk of getting additional cross resistance (and loss of additional treatment options).

There should be a number of adequate treatment options, but getting it right on the next round is essential. I wouldn't want to predict which regimen to use now, but I'd encourage you to write back after you've got the resistance testing results. Newer PIs, like tipranavir (Aptivus) and darunavir (Prezista), with either a NNRTI or enfuvirtide (Fuzeon) should form the basis of an effective and suppressive drug regimen.

Best of luck, BY



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