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follow-up to is genotype a gd idea
May 27, 2001

Thank you for your reply.You said that you usually order a genotype at time of treatment failure or start of treatment,and in my case re-start,I was told that if I didn;t do the genotype at aprox 2-3 weeks after therapy it would be useless,because any resistant virus I might have had will have been outgrown by sensitive,wild typevirus.What is your opinion? And when the time comes for me to restart my meds,3tc/abc/sustiva,would you comment on the fact that it is sugg when switching from a pi to sustiva,you should overlap the two for one week so the sustiva can reach proper levels,then drop the pi.It seems reasonable to do this when the time comes for me to restart.What is your opinion on this and which pi would you suggest.Many thanks,Luke

Response from Dr. Young

I think that your doctor raises a good point, in that the viral population can revert back to wild type after prolonged treatment discontinuations (as was seen in Deek's recent New England Journal article). The trick is trying to best time this- the time to appearance of virus varies from person to person, and may take as long as 4-6 weeks for some people. I would think, that on average, if you were to wait 3 weeks, that your virus should have reappeared.

As for switching from efavirenz to a PI, having an overlap has not been well evaluated in this direction; though in the most successful switch study (Dupone 049, CROI8) there was overlap of 7 days when patients were switched from a PI to efavirenz. As long as you tolerate the extra meds, this approach seems reasonable.

Which PI to switch to is a complicated decision, based on a variety of factors: tolerance, pill burden, toxicity profile, potency, salvagability. I think that best advice here is to discuss these options with your doctor.

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