I unfortunately have been infected a virus with triple class resistance. I have never been on treatment. cd4 255 vl 10000. I am healthy with no history of OI's. Now that new agents are availible to which my virus is supseptible I have some options. My doc, who is a great guy wants to start me on raltalgrivir, boosted darunivir, truvada, maraviroc (my trophile test said it would work) and Fuzeon: but Fuzeon only for 6 months then stop Fuzeon once my VL hopefully becomes undetectable. I am told this is a new and somewhat experimental approach which sounds good in theory but am a little worried about restsistance developing to the Fuzeon and not saving it for later. I also worry that the VL will not drop as expected and that I may have to be on the Fuzeon longer term. Any ideas? Thanks so much

I agree with your doctor's chosen regimen. Since I lack some important information in your case, such as your resistance test results and your susceptibility to the PIs and NRTIs, I can't judge the likely success of the regimen completely, nor can I offer other alternatives unequivocally. I will offer some suggestions to you and your doctor, and ask that you share them with him or her at your next visit.

When raltegravir is combined with two active drugs, the chances of achieving an undetectable viral load exceed 70%. If your doctor has good reason to suspect that both darunavir and Truvada will be active, it would be possible to start with that regimen alone. Since you have an R5 tropic virus, you and your doctor can also add maraviroc to that regimen, so that you have TWO new classes of drugs. Here again, you and your doctor would be justified in limiting the regimen to those 4 drugs, i.e. RAL, DRV/RTV, TVD, and MRV. This would allow you to save the ENF to another time when it might be needed.

Another alternative exists as well; etravirine (ETV) was just approved in Jan 2008 by the FDA for use in patients with previous NNRTI failure and EFV resistance. So instead of adding enfuvirtide (ENF) as the additional drug, even for 6 months, you and your doctor could choose to use the twice daily oral drug ETV (as a fifth drug in the regimen) and spare yourself the twice daily injections.

Regarding your question, if ENF is part of a fully suppressive regimen that successfully controls your virus after 6 months, and then it is withdrawn, it is likely to retain full activity if and when you and your doctor choose to use it again.

Your doctor is choosing a strategy to maximally inhibit the drug initially, to ensure that you achieve an undetectable viral load, and then withdrawing one or more drug when full control has been achieved.

As above, I suggest that you talk to your doctor about your questions and these suggestions.