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CROSS X ROADS: Which direction?
Nov 28, 2008

Hello Dr.: I'll be as brief as possible. I am a healthy male at 55. Diagnosed in 2002, no antiretroviral treatment (yet). Prior to 7/07 my vl averaged (6000's) and cd4's (900's). In 7/'07 vl spiked to 203K and have been all over the board since (7K, 33k,66k,48k,etc.). My cd4's have fluctuated also between 550 & 760. This past August my vl was 48K and cd4's 760. This past week not so good; vl 115K and cd4's 550. My doctor is suggesting the following treatment but is leaving it entirely up to me as when to begin: Truvada, Reyataz, Norvir. I am resistant to all NNRTI's and have "reduced response" to all but 2 NRTI/NtRTI's. Most PI's are "maximal response". I have four questions; (1) am I at risk for futher drug resistance because of my high vl; (2) should I begin treatment; (3)is this regimen a good one; (4) should I be concerned about the number of drug classes that I am resistant to?

I am active and healthy with slight neuropathy in my feet for some reason and my AST (63) and ALT (92) have been elevated since all of this began.

I'm thinking to wait a month and retest because of the fluctuation; however, I do not have a problem beginning treatment now if the benifit out-weigh the risk of making matters worse in the long haul.

Thank you for all of the hard work and dedication. I look forward to your response.

Response from Dr. DeJesus

If you have never taken HIV medications, having a resistant virus means that you were infected with that resistant strain. You are not at risk to further develop even more resistances by not starting HIV medications regardless of your viral load. Although ideally we would prefer you not to have any resistance, at this point, you should not be more concerned about the resistance that you already have because this is something that it not going to change. The best measure for you to take is when you start meds, make sure the regimen is potent enough to overcome all those resistance mutations, so you do not fail that initial regimen.

The question of when to start HIV medication is more complex. The guidelines recommend anyone, otherwise healthy with a CD4 under 350 to start meds; and for patients between 500 to 350 cells to consider treatment. But regardless the CD4 count, this is a decision that needs to be individualized. Important considerations are for example the rate of CD4 decline over time, the presence of any symptomatology that could be explained by the HIV infection (you mentioned you have some neuropathy?), and even the fact that untreated people are potentially infectious to others.

I cannot comment about the regimen that your doctor selected because I do not have all the information available, but seems to me, that if you have that much resistance (nucleosides and some PI mutations), a consideration needs to be given to put you in a slighter more potent regimen, perhaps using darunavir instead of atazanavir (Reyataz), or considering using raltegravir on your regimen. Good luck!



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