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HIV Drug ResistanceHIV Drug Resistance
          
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Never low, never high
Feb 23, 2002

Doc,

I have been on medication since 1991, having gone through the AZt only, AZT-DDC, DDI-Saq-d4T, then finally added norvir. Been on the last regime for last 4 years before switching last year to just combo of Fortavase and Norvir, based on a few studies showing this may work and reduce side effects. I have never been undetectable. My VL ranges from 1000-15000 over the last 6 years. T cells from 400-800. CD from 20-28

My strategy is to save my future options as long as possible. Am I right? Should I switch? Am I getting benefit? Can I stop for awhile? Why do I remain stable if I have resistance?

Thanks

Response from Dr. Little

Although I would like to give you a simple answer, this is not a simple question. In general, the best possible way to avoid the development of drug resistance is to maintain your viral load below the limit of detection. Given that your viral load has not been undetectable while you have been on therapy, I would presume that you do have drug resistance mutations to one or more of the drugs you have taken now or in the past. I am also surprised that your viral load has not risen higher over the last several years given my assumption that you do have some resistance. It is possible that your viral load is naturally low and that the drugs are keeping your viral load lower than it would be off of therapy, but are not acting as effectively as we would really hope. In terms of what to do - I would get a resistance test and use this to try and design a treatment regimen that has a better long term possibility of maintaining your viral load below the limit of detection, while still preserving the maximum number of future treatment options. It is impossible to advise you to stay or change without this advice. If you are unable to obtain a resistance test, then I usually use changes in CD4 cell count to guide my decisions. That is, if your viral load is detectable and low, but your CD4 is less than 200 or falling rapidly, I would switch. If your viral load is detectable, and low, AND your CD4 is high (ie greater than 300-400) and stable, then you may do OK continuing with your current therapy under close supervision - realizing that you may well develop additional drug resistance mutations over time. If your CD4 is between 200 and 400 - then I look at the past trends. I hope this helps.


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