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Starting drug therapy before resistance test?

Feb 11, 2015

Dear Dr. Young,

I was infected around 4 months ago, had some early symptoms and I recently diagnosed (confirmed by Western Blot). I just want to start the drug therapy as early as possible. Because I read the latest reports regarding to starting the therapy while CD4 count is still high. My CD4 is 549 and VL is little over 100.000. My doctor agrees to start the therapy without waiting, but he prefers to see the results of resistance test first, though he seems he is not that sure.

I already gave blood for resistance test today. In my country (Turkey), it takes 1 month to get the result of resistance test (only Genotype test can be done here). So, if I wait for the test results, probably my CD4 count will be below 500, or even below 400. Do you think it is better to start the treatment now and change it (only if necessary) after the resistance test?

Main first line drugs are Truvada+Stocrin here. I would like to ask you; what can be the worst case scenario if I start Truvada+Stocrin now, without waiting the resistance test? Let's say; if I am already resistant to Stocrin, is it so bad to use Truvada+Stocking for a month, before the test result? Does it mean that I will also get resistant to Truvada as well, if it is taken with an already resistant drug (in this case, Stocrin)?

I guess it is a controversial subject but your opinion is very important to me. What could be your first line treatment combination in this case (instead of Truvada+Stocrin)?

I hope I didn't ask too many questions at once, but I am too confused and worried.

Thank you very much for your support in advance. I will be very glad if you answer my email as soon as possible.

Kind regards,

Murat S.

PS. Sorry for my bad English.

Response from Dr. Young

Hello Murat and thank you for posting from Turkey.

No worries at all about your english; it's excellent.

Baseline resistance testing is recommended (at least in countries where the test is routinely available), since a significant minority of people become infected with resistant virus. Indeed, the main reason for this is that the most commonly transmitted resistance causes resistance to the commonly prescribed drug efavirenz.

There are circumstances that might prompt initiation before resistance test results, like among people with very low (<200, certainly those less than 100) CD4 counts or those with active opportunistic infections (where waiting too long to start is associated with increased risk of death). In this situation, we typically try to initiate medications that have very low, if not zero, rates of transmitted drug resistance, like boosted protease inhibitors or perhaps, integrase inhibitors.

In your case, with a normal range CD4 count, in my opinion, it'd be better to wait for the resistance test results. There's little risk in having a HIV-related complication in the roughly two weeks it takes to get the results, and you don't risk the possibility on being on sub-optimal two (or one) drug therapy.

Hope that is helpful, BY



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