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Moving forward
Nov 15, 2007

Hello.

I am recently diagnosed, and wanted to ask whether:

a) Resistance is inevitable? Does this eventually happen to all those on meds, even if they strictly adhere to their regimens? What is the longest any of your patients have stuck to the same combo without any resistance issues?

The media where I live (Cork, Ireland) seem to be very hung up on the fact that 80% of those around the world on meds have resistance to 1 or more class of drugs - do you believe that this is truly an accurate figure?

b) Going forwards, how do you think the landscape of HIV treatment will evolve in the next 5-10 years? Do you feel that injections/patches/inhalers may take over from those drugs currently in tablet form, thus possibly ending any side effects issues?

c) Can you see a day when a therapeutic vaccine, i.e. maybe a once a year injection will take over from HAART? Have there been any successes of late in this field.

d) I am considering trying for a baby in the next year - please can you advise which regimen is best in this situation (I have read lately that there is another drug which can be administered in labour to reduce the chance of my offspring developing resistance in the future - is this correct? If so, which drug is used?

Thank you for hopefully taking the time to answer my questions.

The last few months of my life feel that they have been lived through a thick haze, however, I feel that with the support of my doctor, friends and family, I will come out of this a stronger person.

Regards,

Marie.

Response from Dr. Wohl

Dear Marie,

We think of resistance as being something that happens, like earthquakes and lightening strikes, only once in a awhile. In fact resistant virus is constantly emerging. HIV replicates (makes its own offspring) countless times a day. Among that multitude of virus are drug resistant mutants. Keeping those mutants at bay and in the minority is essential for long term success of HIV therapy. Bottom line: don't create the conditions that allow drug resistant mutant HIV to prosper.

HIV therapy reduces the rate new virus is created, thus decreasing the emergence of resistant mutants. If taken regularly and correctly, mutants are suppressed. Combination therapy hedges the bet that a mutant resistant to all the HIV meds will emerge and become predominant. When adherence is suboptimal, the resistant strains of virus have an advantage over the drug sensitive virus and can further mutate to survive in the face of drug.

I work with patients who have been undetectable for 10 years or more. They are super conscientious about taking their meds and do not drink, do crack or meth.

So, resistance is a fact of life. Keeping it contained is the key to long term success.

As far as toxicity of the meds, patches, inhalers or injections will not solve that. They only are a different way to deliver the meds. Anyone on Fuzeon, an injectable med, will attest to the fact that it does not eliminate side effects. The good news is that newer HIV therapies seem to be better tolerated than older meds. Non-oral delivery systems may be useful for people who dislike taking pills and will offer convenience.

Vaccines are important but it has been very difficult to design an effective HIV vaccine. A vaccine that boosts a persons ability to fight HIV I think is realistic. However, I do not see this supplanting antiviral meds.

Having a baby is big decision and it sounds like advice from friends and medical professionals is available to you to help you make a decision that is right for you. Many would recommend you start on an effect HIV regimen during your pregnancy and continue on that through labor - rather than just take something during delivery. Kaletra and Combivir are popular and there are data to support their use in this setting. Again, talk this over with your doctors as the selection of HIV meds has to be individualized. You should have a drug resistance test done to make sure you were not infected with a resistant strain of virus.

DW



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