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Resistant mutations
Jun 7, 2011

First of all thanks for all you do to help folk fighting this virus!!I was diagnosed last year having come down with the OI PJP which put me in intensive care and almost took my life. Due to my crack team at the hospital and my otherwise being very fit(I teach high cardio aerobics) I was able to pull through and recover. At that time my CD4 Had fallen to zero and my VL was 372000. After an initial period of atripla my VL was not responding at all ..so a genotype was performed. This revealed a highly resistant strain that I inherited containing A62V, K65R, K70E, V90I, K103N, V108I, M184V, H208Y, T215S. Whew! So, my wonderful ID MD switched me to Intelence/Isentress/Prezista-Norvir twice daily 200/400/600/100 mg dosages respectively ...and after only 30 days my VL plummeted to undetectable. I am 100 percent compliant and committed to my regimen... I take my first round with breakfast trying to keep the time between 0800 to 1000.... And my evening round aprox. 12 hours later at 2000 to 2200 of course with my meal. So I suppose my question is ...is it first common or at least not totally rare to have that many mutations? Obviously my regimen is working so far....and I know it's still early .. But is the prognosis good that with continued compliance that this regimen will hold down the "fort"? What in addition to my medication adherence can I do to enhance the success? I have gone back to teaching aerobics and feel stronger than ever. My provider did do a Vitamin D level on me last time which shows while not deficient ..Shows insufficiency at 27 just below the 30 cutoff. I started taking VitD supplements in efforts to try to boost my level. Am taking a 400iu tablet morn and one in evening. I have read that this may not be enough ? But at least it is a good start since I am just under the lower limit? Thanks again for all your help!

Response from Dr. McGowan

Sorry to hear about your stormy initial course but glad that things have turned out well. Your case illustrates the importance of having experienced health care providers who stay on top of things, work with the patient to ensure that the response is optimal and react if things aren't working as expected. We always check the resistance test (genotype) first before starting meds. About 14-15% of people will be infected with virus that carries at least one significant resistance mutation. Sometimes (and perhaps this is what happened with you) the initial resistance test may not show the mutations (you may have been infected for a while since your CD4 was so low) because over time the mutations may fade into the background but can re-emerge quickly once treatment is started. Those mutations can then allow the virus to survive on the meds and over time more build up as the virus gets more fit. So they may not have all been transmitted but once you were on the meds, the virus has its foot in the door and can add more mutations to increase its level of resistance. No reason to expect the current regimen to fail as long as you avoid missing doses and keep the lid on the virus ( that is maintain an undetectable viral load). Also good that your vitamin D levels are being checked and the excercise is very good for your stamina. A balanced diet with lots of vegetables is best. Keep up the good work. Joe



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