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May 28, 2012

Good day Doctor. I am worried about my hiv infection and my new meds. Before of telling my story I want that you know that I am from Mexico and I go with a government doctor with a government assurance. Because of this the service is slow most of the time, with lots of bureaucratic paperwork, and the medications, specially new ones, are extremely controlled. Medications like raltegravir, darunavir, etravirine, maraviroc and enfuvirtide need an extra approval of a federal comission(called CORESAR) of supposely named "scientist" and "ph D" to use on a patient. I have been hiv positive since 5 years ago, my inicial treatment were kaletra and truvada because my hiv genotype resulted in a high resistance virus. For almost 2 years and a half I have a indetectable virus level but since almost 2 years ago, I have a viral failure with new resistances to kaletra and truvada, evaluated by a hiv genotype test. One year ago I finally received only one new medication, raltegravir, that was added to kaletra and truvada. I ask my doctor why only another new one med, and he said to me that this was the order of CORESAR. At the first test my viral load went down and my CD4 count went up, but since beginning of january my viral load started going up again. So I went again to do another genotype test thinking that this new one would evaluate integrase resistance(in other case it wouldnt had any sense because I had another genotype test and resistances are not reversibles) , but the new test didnt evaluate integrase resistance so I dont know if my virus is resistant to raltegravir. Apparently my doctor didnt know too that new genotype test didnt include integrase mutations evaluation, I want to think that. My doctor stopped to give me raltegravir recipes since 2 weeks ago and is asking to CORESAR to send darunavir and etravirine as my new medications, with raltegravir. I dont really know what to do right now. At the first time I wanted to find a lab that have a genotype test with raltegravir evaluation included so I would be sure if my virus is resistant to raltegravir and my new medications are fully active. The trouble with this is that I havent found any lab here in Mexico that have in their genotype test a raltegravir evaluation. Even if I find the way to demonstrate that my virus is resistant to raltegravir, maraviroc have the trouble that, according the stuff i have read, when the viral load is going up virus start to use both CCR5 and CXCR4 receptors. My last viral load was 38 000 copies (february 2nd). And my another option enfuvirtide have the trouble is very expensive and I am afraid they wont want to give me that medication, at least until I started to show an illness progession. Sorry for not trusting in them but, unfortunately this country is like this. And the other thing is that I am not very sure government will help me more, because elections are in july and nobody knows what is going to happen, but for sure I know because of the people and the statics the politic party that is in the government will lose. I have a good economic level and I want to offer to the doctor and assurance to buy two of the medications, but not as good to buy three hiv recent medications each month, and never enfuvirtide, is very expensive. I think too I need a recent CD4 count and a new viral load. I havent menctioned that my CD4 is not very related to the viral load, I have been taking proviron(mesterolone) pills I have realized everytime I take this my CD4 count is higher that the last one and when I stop taking them CD4 count goes down.

So, the question is, what do you recommend me to do?


Response from Dr. Young

Hola y gracias por su preguntas,

You describe a difficult situation- the virus you acquired appears to have had drug resistance and then you had failure of your first (but drug-resistant) treatment. Add to this the unfortunate history of having had a single drug (raltegravir-RAL; ISENTRESS) added to a failing regimen; a situation that we've worked to avoid and placed you a risk for the emergence of raltegravir resistance.

RAL resistance isn't measured by the vast majority of HIV care providers, nor is the test widely requested (even here in the US). Nonetheless, given the lengthy time that you've had a detectable HIV viral load while on RAL, it's highly likely that your virus is now resistant to RAL.

The new regimen that's proposed (boosted darunavir with etravirine) might retain adequate activity against your virus, but this is entirely dependent on the drug resistance mutation pattern- it's important to look at the sum of your current resistance tests and all previous tests. This situation applies to all of your proposed medications, including the darunavir and etravirine. If you have access to all of your previous drug resistance test results, you can enter the mutations into the Stanford University HIV drug resistance database. The results are usually very predictive of drug sensitivity (and better than this MD PhD clinical scientist).

You're also correct in asking about the suitability of maraviroc, the CCR5 inhibitor (SELZENTRY). A special test (called Tropsim) is needed to determine if your virus can be treated with this drug. This likelihood goes down in people with previous drug resistance or with low CD4 counts, but by no means rules out the possibility of viral drug sensitivity.

You're also correct in that if at all possible, you'd like to find three medications with good predictions of drug sensitivity. Using a steroid like mesterolone is probably not the best approach, since corticosteroids cause immune suppression while paradoxically increasing white blood (and CD4) cell counts.

Muchos suerte y buena salud, BY

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