Sep 21, 2006
I am a 44 year old male who have received treatment for HIV since age 23. I have been asymptomatic other than an occassional swollen lymph node. My viral load has been on a doubling trend every 3 months or so for about the last year. My current load is 47,000. My T-cells are approx 150 at 7%, which is what they have been for the better part of 14 years. My doctor now wants me to take Fuzeon and TMC114 as he believes this is the only real choice for me. My last phenotype test in December 2004 showed that I was "Resistant" to; Epivir, Videx, Hivid, Ziagen, Emtriva, Viread, Viramune, Sustiva, Crixivan, Norvir, Viracept, Invarese, Lexiva, Reyatiz. In this same phenotype test, I showed "Suseptible" to Retrovir, Zerit, Rescriptor. I am now taking and have been taking Resriptor, Viread, and Kaletra for almost a year. I am now awaiting another phenotype and genotype test results as I want to be sure there are no other options before I move to Fuzeon / TMC114. Can you please tell me based on the drugs that I indicated I am resistant to, are there other options that I should consider, or am I limited as my doctor says to Fuzeon and TMC114?
Response from Dr. Wohl
Your virus is resistant to many of the drugs currently available to treat HIV. In addition, your CD4 cell count, although stable, is low. Persistently low CD4 cell counts along with continued high levels of HIV virus are not good for the body. Dementia, cancers, kidney, liver disease, etc have been associated with persistent immunosuppression and unchecked HIV in the blood. Some of these you may be at more risk for with older age.
That is the bad news. The good news is that there are a slew of new meds that may work for you. TMC114, now called darunavir (Prezista) is a protease inhibitor that is active against many strains of HIV that are drug resistant. A genotype will let your doctor know whether the mutations you harbor are likely to impact darunavir activity. In a recent series of studies, taking darunavir with another agent that has activity against the virus was found to lead to more success in suppressing HIV than when darunavir was acting solo (no surprise). For example, those who had never taken Fuzeon and took it with darunavir tended to do better than those who did not take Fuzeon. IF daurnavir looks like it will not work, tipranavir (Aptivus) might as these drugs do have somewhat disparate patterns of resistance.
In addition to Fuzeon though there are two new medications that also hold promise - one more than the other. TMC125 is a new agent in expanded access now in the US that works against virus resistant to efavirenz, nevirapine and delavirdine (non-nukes). Problem is that with the heaping on of non-nuke mutations, TMC125 loses effect. You have been on delavirdine for a long while and I would be concerned that TMC125 may no longer be for you but, again, a genotype and a smart doc can figure this out. The other med is the Merck integrase inhibitor. This should definitely work. It also is available via expanded access.
So, I would consider using darunavir/ritonavir (if genotype favorable, if not consider tipranavir), integrase inhibitor, AZT/3TC (just to help keep the virus mutated and less fit to these meds), Fuzeon and possibly TMC125 (again depends on resistance). You could start on this kick-ass regimen and if have trouble with Fuzeon, stop it. You would need to take this absolutely exactly as directed to avoid further trouble. Were sucvh trouble to emerge, there are other drugs in the pipeline to come to the rescue but not many. This will be your best shot (no pun intended) for a while.
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