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Treatment a week after infection
Jan 28, 2007

Hello,

I was infected a week ago as confirmed by a virus test. I had started PEP treatment immediately, but the pharmacist wrongly gave me a dosage of 250mg Viracept twice daily versus the prescribed amount of 1250mg twice daily. This was in combination with Combivir.

The error was found 3 1/2 days later when getting a refill prescription. A viral test was run which proved positive. Since that date I have been taking the prescribed dosage.

My Doctor says to complete the course and wait after that, but I am keener on more aggressive early treatment. I am awaiting results on resistance tests.

At this very early stage of diagnosis, I would like to know your feelings on recommendations regarding continued early treatment with a change in medications which I am very motivated towards? Obviously I am bitterly upset with the pharmacist's error.

Many Thanks for your consideration and time for this great site,

Al.

Response from Dr. Wohl

It sounds like there was an exposure and that PEP was started soon thereafter but, an HIV viral load test was done and is detecting virus. If this is the case, then a key consideration is the amount of virus being detected. Low level virus may be a false positive. However, if tens o fthousands of virus are detected on these tests (should be confirmed with a second test) and you are also HIV antibody negative, then you are in the acute phase of infection.

I agree with you that staying on Combivir and Viracept may not be optimal, although, no one knows exactly what is best in this situation. However, it is hard for me to believe anything less than fully potent HIV therapy is best. Viracept is not a very potent medication relative to other similar HIV drugs. I would consider switching you to another drug such as Kaletra, Lexiva or Reyataz - the latter two should be taken along with small doses of Norvir. Hopefully, an HIV resistance test was done as this may help your doctors understand what drugs are most likely to work.

Treatment during acute HIV infection is still quasi-experimental. Many clinicians are treating those in the earliest stages of infection in an attempt to preserve the body's immune responses against HIV. How long to continue treatment started during acute HIV is not known. Some stop after a year, others after 2. Longer term therapy is not typical. After therapy is stopped, the viral load will be checked and will hopefully be low.

Lastly, I am unsure that the pharmacist's error made a big difference in your becoming infected. There are data to suggest that AZT alone (a drug in Combivir) can reduce the risk of occupational HIV transmission and we know it drops the rate of mother to child HIV transmission. Certainly, being on full dose Viracept would have been nice.

DW



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