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Follow up to Dr. McGowan's Answer
Dec 23, 2009

Hello Dr. McGowan,

Thank you very much for replying to my question. to follow up, could you offer some suggestions on new combos? I ask because my dr doesn't feel comfortable switching me as she worries about what resistance I have. Oh, and yes, I am 100% compliant with my meds. Thank you!! Alex

The original emails are below:

I was diagnosed HIV+ in 1997. My first combo was Viracept, Epivir and Zerit. I was on those meds for several years until they stopped working and my dr switched me to Trizivir alone. After several months of that not working, he added Sustiva. That brought me to undetectable for a while. For the last 5 or so years, I've remained on that cocktail even though my VL is usually between 300 and 800. Since it doesn't get above 1,000, my dr doesn't want to switch me since we can't do a resistance test. I know there are some new meds out there now - do you think I should switch - and, if so, to what? Or do you think it's best that we stay the course and wait until my VL goes over 1,000 and then do the resistance test? Thank you very much for your time.

Alex

Alex,

It is clear now that having an undetectable viral load is the goal of antiretroviral therapy for all people. In your case it would seem possible to reach that goal with the availability of new medications. It is clear your current meds are not working and I would change the combo. As long as you are committed to treatment and are not missing doses, you should switch to a combo that would get your virus undetectable...even without a resistance test available an effective combo could be found for you.

Best, Joe

Response from Dr. McGowan

Alex,

Even if the viral load is below 1000 you can often get a result on the genotype test and that should be attempted (if it has not) to use as a guide.

You have been on zerit, epivir and trizivir as your "Nucs". These meds share certain resistance pathways. After all this time one should assume a fairly high level of resistance to these drugs. There may be some benefit from Truvada, but it may not count as a fully active drug. But we only have to bring down the viral load by less tah 1,000 and it would be more likely to work than what you are currently on.

Next, your only protease inhibitor was Viracept..failure of that could lead to protease resistance which might be overcome with a boosted protease inhibitor such as ritonavir and darunavir. The POWER studies showed excellent response for patients with extensive prior protease use when darunavir was used with other active meds.

Lastly, you can expect activity from a new treatment class: the integrase inhibitor Isentress. In addition, if the viral load is close to 1,000 you can have a tropism test done and you may be able to use a CCR5 antagonist (maraviroc). Up to half of people who have been infected for many years with HIV will still have virus that maraviroc will work for.

So there are active drugs for you and combining 3 (or more) together should work.

Best, Joe



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