May 11, 2007
Dear Dr. Wohl: I started therapy very late when in was diagnosed with HIV and my CD4 was way down to 24 and Viral very very high. I went on Triomune + Didanosin - the latter to balance the effect of concurrent TB infection. I did very well on the regime except for some fluctuations the Viral load has as of three months ago dropped to 60 and CD4 gone to 501.
With the TB therapy over my Doctor discontinued the Didanosin and cut the Stavudine from 40 to 30. However my CD4 has dropped to 375 and i am going for a viral load. My Doctor is concerned and is mulling over what could be the reason. Could this be a standard oscillation in the CD4 or signs of resistance onset requiring a change of regime ? I am deeply concerned. What could be a good regime to replace the Triommune ? What about the newer drugs available under expanded access or should they be kept in reserve ?
Response from Dr. Wohl
If your viral load is undetectable now then drug resistance is much less likely. It may well be that this drop in CD4 count is indeed just some fluctation in your counts and not indicative of a trend toward a sustained decline in these counts.
Triomune is d4T+3TC+nevirapine. Were this regimen to fail, a combination including a protease inhibitor would be next. There are newer drugs coming out in the US that are effective at treating drug resistant virus but are not likely to be used as early as second line (that is after the failure of the first regomen). Rather, these will be reserved initally for more treatment experienced patients.
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