Apr 8, 2001
dear dr, I started on nevirapine, lamivudine and stavudine when VL was 33000 by RT-PCR and cd4 was 243. after 20 weeks, VL is 29000. MY drug adherence has been >98. should i go for a change in the regimen to PI's. thanks in advance.
Response from Dr. Cohen
Well - something doesn't make sense here, and before a switch, I would want to figure out why this didn't work. Since a triple combo like the one you took almost always does.
Well, assuming the viral load of 29 thousand is real and not a lab error (and lab errors are rare but do happen - so I would first just recheck that test - send it again perhaps...) then there are only a few other possibilities as to how this happened.
First - was your HIV sensitive to these three meds? You don't mention if this was your first combo or not. If yes -then perhaps you are one of those who have a strain of HIV that has resistance to one or more of our commonly used meds. In surveys done in the past few years - we have learned that at least 5% - and as high as 25% - of those who have never taken a pill can have acquired a strain of HIV that has resistance to some of our commonly used medications. And - for example - if your strain even just had resistance to the 3TC/lamivudine - then the combo would work only for a short time - and you might see results somewhat like you describe. Or perhaps this was not your first combo - since 3TC is often used in other first combinations - and also one of the meds that HIV can create resistance to if the combo is not fully suppressive. In which case this combo would have the same problem.
So - is it time to use the PIs? Well - with a CD4 count in the 200's - it is certainly time to define a combo that will work well for you. Whether now or in the near future, you certainly will need to do something soon enough. And given this viral load on nevirapine - you cannot rely on any of the nonnucleosides we now have - since if there is resistance to one - there is resistance to them all. Perhaps it is time now to get some test of resistance to see what your HIV strain looks like - as this may help increase the odds of what you do next. Since it is hard to know how much potency you have left in any of the nucleosides either - from your unchanged viral load - it sounds like there may not be much there either. My guess is that you might need a combo based on a two PI strategy - as we have studies in the past few years showing these can work even on their own. And other studies are now being done - both by our group here in Boston and elsewhere - to update our knowledge with newer dual PI based combinations for those with a similar challenge.
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