Dear Doctor Wohl, its me again... the worried sister of the guy who badly seroconverted last year and was immediately put on haart (now Sustiva/Kivexa). His labs are constantly improving (690 cd4, 37%, undetectable), but my questions are: (1) Which are the data available about Sustiva/Kivexa combo, as far as the capacity to keep viral suppression / mutations and resistance / side effects / forgiveness of sub-optimal adherence are concerned? (2) Is adherence the key factor in preventing resistance? What is the role of other factors and how predictable are they in a regime failure? (3) As he was immediately put on haart (200 cd4, >500.000 VL, pneumonia and meningitis), how can be his viral set point determined? In other words, how to determine a prognosis? (hes perfectly adherent, eats healthy, goes to gym, hes very active and thinks positive) (4) Has fermented papaw any positive effect on immune system and cd4 count? (5) Any news about therapeutic vaccines? And what about gene therapy (any comment on VIRxSYS VRX496)? (6) Is flu vaccine recommended? (7) Just a matter of curiosity (if its not too much..! And sorry if its stupid); lets suppose that in the future an haart combo will lead to a viral clearance: how to measure the eradication? I guess its not only via hiv test

Thank you so much, dear Doc, for your invaluable and precious support to all of us. S.

Yow! Where do I begin?

Okay, there have been numerous studies of Sustiva plus lamivudine (a component of Kivexa - also called Epzicom) and a third drug. Nothing has beat these combos as far as getting the virus undetectable.

Adherence to potent is absolutely the key factor in keeping the viral load down and resistance from developing. There are other factors (i.e. drug interactions, poor absorbsion of meds) but sub-optimal adherence is the leading reason for drug failure.

Don't worry about his set point. If I remember correctly, he was really sick prior to starting meds and there were some good reasons for not stopping meds any time soon. In others who start HIV meds during acute infection, the set point can be determined by stoppingt the HIV meds after a period - usually about 2 years.

His prognosis is best determined by his viral load and CD4 count. The higher teh CD4 and lower the viral load, the better. His current numbers suggest a low risk of any bad things happening for years, if ever.

I know nothing about pawpaw.

There are no vaccines that have been found yet to be sufficiently effective in the treatment of HIV. That will likely change as new data emerge, Gene therapy is not likely to be an option for many years.

The flu vaccine is definitely indicated.

Eradication of the virus will require demonstration that stopping HIV therapy does not lead to detection of HIV in the blood or other tissues. As the HIV tests detect antibodies to the virus - which remain for years to a lifetime - proof of eradication will require viral load tests and other sophisticated tests for hidden virus.

I hope this helps.

DW