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HIV Drug ResistanceHIV Drug Resistance
           
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Phenotype HIV 1 Virtual
Sep 10, 2002

Dr. Little,

I'd appreciate your thoughts. 300k VL cd4 4 nadir hep B. 09/01 Trizivir Viracept drug naive. 100 adherent <50 cd4 10 by week 24. 7/02 vl 114 cd4 10, 8/02 vl 344 cd 10. 9/02 getting test in title. We want to switch but need to know the nucleoside resistance if any.

Will this test give me the answers I need. I'd like a genotype but can't wait for enough verimia to get one. I can't stop meds cd4 to low vl to high at nadir. I want to use a Sustiva based group. Viread and Epivir for HIV and Hep B. I want to keep ABC on board too because we treated through a 104 degree fever when I started and I'd be afraid to ever restart it. What do you think. Of course this is all if I have resistance.

Response from Dr. Little

In the short time that you will need to wait for a phenotype test result (if your viral load is high enough - you are right on the edge of what is routinely possible) - I would be inclined to make a conservative switch that would probably result in a short period of overtreatment (i.e. with more than the necessary number of drugs), but would not risk the further development of any additional drug resistance in case you guess wrong based upon the clinical history alone. In this case, I would think that the most likely drug resistance mutations would be to lamivudine (M184V) and possibly nelfinavir (D30N). Based upon this - if you know that you were drug sensitive before you started any antiretroviral therapy, you could consider an efavirenz (i.e. sustiva)-based regimen. You could consider dropping nelfinavir and keeping trizavir and adding tenofovir while you wait for your drug resistance tests. You will have to make some "best guess" decisions though if your viral load ends up too low to permit performance of a phenotype test. In this case - my guess would still stand, though you might want to continue the 3TC despite the chance you have HIV drug resistance in the hopes that it will add to your potency for Hep B. And although not as popular, you might still find that a protease inhibitor based regimen was also a good option. I would discuss all these options with your doctor to come up with a treatment regimen that you are both comfortable with.


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