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ARV's and Alcohol: an update and another question
May 27, 2009

Hi Joe,

Thanks for your reply to my previous posting on ARV's and alcohol. I will certainly limit my alcohol intake in future, when you consider all the risk factors that you listed. (Although it's difficult with an ever increasing social calendar!). What I would like to know was the impact, if any, on the effectiveness of the ARV's during my alcoholic binge that lasted a couple of months last November? I was undetectable at the time but am not sure if this means that no LONG TERM DAMAGE was done to the durability of my regimen. I'm on a boosted PI regimen (ATV) with a couple of nukes (TDF, Combivir), and am still not sure how long you have to wait for an effect to show up. I mean, (my understanding is) the PI's have a high genetic resistance barrier, meaning several mutations are required to loose viral control. But does this mean I could have accumulated maybe 1 or 2 mutations during these episodes, without knowing (i.e., still undetectable) but weakened the overall LONG TERM durability of the regimen? Lastly, I was originally diagnosed with a transmitted mutation T215S. My Doc put me on TDV, Combivir and Sustiva (which was substituted for ATV(r), as described in a previous posting), but after looking on the web, especially the Stanford database, it appears that there is only limited (if any) resistance to TDV, therefore why wasn't I put on Atripla as T215S doesn't affect FTC? Again, thanks for the brilliant effort. Cheers Michael.

Response from Dr. McGowan


Your question is a very good one. We cannot detect mutations that may be present once the viral load is suppressed. If your viral load remained fully suppressed while you were drinking then it is very unlikely that any resistance mutations would have slipped in. The virus must be able to grow in the presence of the medicine to select for the resistance. Late breakthrough with resistant virus after several months of being undetectable is rare unless adherence to treatment slacks off. So, the longer you stay undetectable the more likely it will remain that long as you maintain adherence. This would be best if you avoid alcohol binges. The T215S mutation by itself would not cause tenofovir resistance, it may be a marker that the virus has started down the path toward drug resistance. In general combinations that include NNRTIs, such as Sustiva, are best if they include at least 2 fully active additional drugs. Your doctor may be cautious to insure that you have 3 active drugs and may be concerned that the resistance test is just showing some of the mutations and not all. A baseline resistance test (before meds are given) may not show all the mutations (some may fade into the background). The T215S may just be a "footprint" indicating that this virus has been exposed to ARVs in the past, so a broader treatment might be best.

Thanks, Joe

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