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Virologic Breakthrough?
Mar 21, 2002

Dr. Little:

I began Combivir and Sustiva on Feb 22, 2001, with a baseline of 211 T's and 76,000 VL. After 14 days, results were 228 t's and 2,091 VL. June 30 results: 330 t's and 121 VL. September 28 results: 360 t's and <50 VL. January 16, 2002, results: blood taken 4 days after mild case of stomach bug - 290 t's and 190 VL. February 16 results: 320 t's and 130 VL.

I'm 100 compliant and have adapted perfectly to the regimen, and I want to save it. My doctor says that, based on the Feb repeat tests, the meds continue to work well and, to quote him, "You're doing fine. Don't worry. And, I'll see you at your regularly-scheduled three month visit (i.e., mid April)." Do you concur with his advice? If not, what would you recommend? Should I promote to him a phenotypic resistance test NOW even though I have less than the threshold requirement of 1000 copies (to perform a meaningful resistance test)? How should I discuss any suggestion you have with him so he doesn't think I'm becoming a "problem patient" or questioning his judgment? Thanks so much.

Response from Dr. Little

The choice of when to consider a treatment regimen a "failure" is not always simple. If we had more choices of drugs without cross resistance, then we might move people off of potentially failing regimens more rapidly than we do. Because we do have a limited list of choices and we hope to treat people for decades - I do think that it is better to be a bit cautious about switching too rapidly - though the data does suggest that the earlier into a failing regimen you switch, the better. You are sitting right on the cusp as I see it. There are data that should be a bit reassuring that suggest that viral load "blips" of less than about 200 do occur in many patients on potent therapy and do not predict impending virologic failure. So two isolated values of 190 and 130 would not make me panic - but rather review compliance (which it sounds like is not the problem) and any possible drug interactions which might be lowering your antiretroviral drug levels. If these are not issues, then I would repeat another viral load in 1-2 months which would be March or April. The choice of exactly when to test is one of judgement - but by stict data-driven guidelines, your physician has made the correct choice I believe.


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