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No Options Left?
Jan 20, 2002

A friend has been told by very experienced clinicians and researchers at our local university-based HIV clinic that she is resistant to all known meds (following years of treatment and lots of sophisticated resistance testing) and that there is nothing in the pipeline for her for at least 2-1/2 yrs. They apparently don't think she has that kind of time (though she is currently feeling well) as they have advised her to "put her affairs in order." Can this be a true appraisal of her prospects? Do you see any other options for her? Where can she get the very best second opinion?

Response from Dr. Little

There are unfortunately occasions when patients will have developed resistance to all known antiretroviral drugs. In this case, one can look to the future and the new drugs coming - the difficulty is that this patient may not have anything to pair with the "new" drug (ie, a new drug paired with three or four "failed" drugs - will typically yield failure). This does not mean that there is no hope, but it may mean that the advice to "put her affairs in order" is not unreasonable. We as providers struggle to always try to offer some hope and at the same time not mislead our patients. I think that based upon the story you have outlined, your friend should put her affairs in order. This does not mean that she has no options. There is quite a bit of data to suggest that some therapy (ie even non-suppressive therapy) can prolong life compared to no therapy at all. Also, depending on your friend's T-cell count and the rate at which it is falling, she may be well enough to benefit from some of the newer drugs that are coming. Especially if they can be paired with each other. In terms of where to get another opinion - she can ask for a second opinion from another provider in her own clinic (we as physicians do this all the time on our more complicated patients). Or she can ask her physician to refer her to someone who can provide her with this information. Certainly, if her options are limited, the prophylactic medications become critically important in the prevention of HIV-related infections, while waiting for better therapies to come along.

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