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Why is genotype testing required for treatment naive patients?
Jul 30, 2010

My partner was recently diagnosed with HIV and 13 T-cells. We want to get him on meds immediately and the doctor we are seeing won't write a prescription for 4 weeks because he wants the results of the genotype test before prescribing. My partner got it from me and I was treatment naive until about six weeks ago. He has had no other partners and there is no way that he could be resistant to any meds since my genotype came back clear.

That being said, who cares if he is resistant. If he is resistant to Truvada, for example, and he starts a regimen of Truvada tomorrow, the worst thing that can happen is that he won't get any benefit from it. But not taking anything is even worse because for the next four weeks, he is stressing out and in total fear of dying. His skin is covered with pock marks and is to rough to the touch that he looks like an alligator. When asked, the Doctor with whom our PA talked about my partner's condition, said "He needs to get on meds right away" 4 weeks is not right away.

Furthermore, we understand that it takes a while to get ADAP to go throughl, but his boss is willing to shell out the first month or two (understanding that it could be as much as 7000 dollars) just to make sure that he is okay.

I am about to find another Doctor who will start my partner on the same regimen that I am and then my PA will have his hands tied. But before I do that, I would like to have some technical data that I can present to him to show that even if he is resistant, starting a regimen (which he is resistant to, for example) will not be as bad as doing nothing but waiting to die.

Any advice or technical reference you can offer would be greatly appreciated. Thanks in advance for your support. I apologize if I sound confrontational, it's just that he is the most important thing in my life and I don't want to lose him.

Jase

Response from Dr. McGowan

Dear Jase,

I am sorry to hear about the stress you and your partner are experiencing.

A couple of points to consider:

1) Since your partner's Cd4 count is 13 it is likley that he has been infected for many years. I do not know how long you have been together, but it is possible he was infected prior, we may never know that for sure. Therefore it may not be best to assume his virus carries the same resistance pattern as yours. 2) It may seem very risky to wait a couple of weeks for a new medication, but, assuming he is using prophylaxis for PCP and MAI, it is not that long (since he has likely had this low CD4 for a while). I agree that the stress is a huge factor and needs to be considered. 3) There is a downside to staring a medication to which the virus may be resistant in that not only may it not work, but a non-suppressive regimen can lead to development of more broad resistance. Many of our medications are related to each other (for example truvada is in the NRTI class of meds..it shares some features with the other NRTIs) and mutations in the virus that develop against one med can also effect related meds. We call this "cross resistance". For example, it is possible for a person to have a virus that has resistance against all the NRTIs even though s/he may have only used one medicine, likewise with the NNRTIs and PIs and we are seeing that with the integrase inhibitors as well.

So making the first choice of medicines is a very critical choice.

What I sometimes do when I really want to start someone on meds quickly and do not have time to wait for a genotype is to start a very broad treatment (with a "boosted" PI and maybe even a 4-drug cocktail) to which transmitted ressistance would be unlikley and then simplify it later when the genotype results come back. Perhaps you could discuss that option with your doc.

I hope all works out well with you and your partner.

Joe



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