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Do I need to change medication
Aug 7, 2006

Dr Young sir, I have a question that is troubling me and would like your advice before my next appointment with my Doctor. I have been on Truvada and Sustiva for 22 weeks now. My initial VL was >100,000. Over the last 5 months it has gone down to 1600, then 330, then 300 and at week 18 was 200. My CD4 has remained about the same at about 300. I do not know my CD4 % as they have never been mentioned to me. Although I intend to ask at my next appointment. I adhere 100% to my medication and have had no side effects, apart from the occasional bizzare dream. My next appointment and testing is due at week 26. If after that my VL has not reduced to undetectable i.e. <50 should I change my medication. I have read so much information that indicates that by now I should already be at that stage and am extremely anxious I am not. I had resistence tests before starting this regime, could I have developed resistance already dispite taking my meds properly. If you suggest I do change, what combination would you recommend next, preferably without the fat loss side effects. I hope you will answer this question as at present I am very anxious and would appreciate your expert opinion so I feel prepared for my next appointment. Please be honest and say if you think I am worrying premiturely and apologes if that is the case. Thank You in advance.

Response from Dr. Young

Thanks for your post.

The key issue for your situation is what your baseline viral load really was-- greater than 100,000 could mean 100,001 or 1,000,000. Persons who have exceptionally high viral loads (like 1,000,000) can take longer to reach less than 50 copies than those with lower viral loads. In this view, the key marker is the magnitude of the initial viral load decline; it would appear that yours is well within the expected range.

With your excellent adherence, and baseline resistance testing, I'd be relatively happy with the response. I share some of your apprehension, as viral loads less than 50 ease the mind on the fear of resistance.

Speaking pragmatically, I'd continue to monitor your labs while your still on your well-tolerated regimen and not change things for now. Do look at the CD4%, this may provide laboratory evidence of continued immunological improvement, despite the low viral load. If there was resistance, it'll likely be to the efavirenz (Sustiva) part of the regimen first; hence stopping now wouldn't allow you to go back to this medication anyways.

A future switch would likely have to be on a protease inhibitor- many of the newer PIs are not strongly associated with lipodystrophy; we've certainly had very positive experiences with patients' tolerance of first-line boosted PIs.

I hope this is helpful. BY



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