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Drug Resistance
Jan 1, 2002

Dear Dr. Little,

I am a bit confused. There are so mnay statements stating that a person can live a norma l life span on HAART but it seems that everyone will develop drug resistance to their meds after a while. Why the conficting messages. I am on COMBIVIR and SUSTIVA and 100 compliant. My last test result is CD4 738 (39), VL undetecable. I am very comfortable on this regiment but I wonder when the resistance will occur. Your thoughts would be appreciated.

Thanks

Response from Dr. Little

The conflicting messages come about because of the following differences. From a strictly medical perspective, there is not reason to expect that drug resistance will occur at any defined period on any specific therapy - as long as the viral load remains undetectable throughout the period of therapy. This means that most people fail drugs because - they had pre-existing resistance (from prior therapy failures, or transmitted from the person who infected them) and then took suboptimal therapy, or became noncompliant to a degree that permitted drug resistant virus to develop - and then the drugs fail. If you are 100% compliant, AND your viral load is less than 50 continuously - your risk of developing drug resistance is very small - note - not zero. Since we only measure viral loads down to 50 copies, we cannot say for sure that viral replication has been completely shut down - even in someone who's viral load remains less than 50 for prolonged periods. Thus it is possible (though unlikely) that drug resistant virus may emerge. The reason that many messages conflict with these statements, is that many people are unable to maintain the tough schedules necessary to maintain 100% compliance indefinitely - AND - many people who started therapy before 1996-1997 received what we would now consider suboptimal therapy - and through no fault of their own, have developed drug resistance which is now difficult to overcome, even with our more potent treatment agents available since this time. But, for people (like yourself) who start a potent regimen from the beginning and do not have any evidence of transmitted drug resistance (something that few people are tested for at present), your are unlikely to develop drug resistance if you remain 100% compliant and your viral load is sustained at less than 50.


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