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HIV Drug ResistanceHIV Drug Resistance
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Feb 21, 2004

I had a Geno and a Pheno test done, because I had a small bump in my viral load, from undetectable for many years to 200, but at the time of the test, the blood used came up with undetectable viral load again. Both Companies sent back results showing some resistance patterns. My Doctor wanted me to change my combination, but I was hesitant. I contacted both labs and spoke to the head quality control person at one, and one of the head Doctors at the other lab. I was told by both not to belive the results that were sent to my Doctor since my viral load was under 500. Why would results be sent to my Doctor if they should not be trusted?? (I also contacted other local Doctors and got another Doctor to agree with my Doctor on changing my medications but another 3 Doctors said not to change).It is now six months later I did not change my medications and I continue to have undetectable viral load and T-Cell count still around 500. I am writting to you to inform you of my experience - for your comment, and to pass on this information.

Response from Dr. Sherer

Your case provides some useful lessons in HIV management.

First, with repeatedly undetectable viral loads and T cells around 500, I think you are doing well on your current regimen, and have no reason for concern about your own status. I advise remaining on your current regimen and continuing periodic repeats of your T cells and viral load.

You mentioned that your doctor advised you to change your medication. Perhaps it was for other reasons, e.g. some previously used combinations are now not recommended, e.g. D4T and DDI together. Also, new long term complications have been observed, i.e. lipodystrophy, which some physicians are avoiding with changes in medications. In other words, I suggest you talk to your doctor about the reasons that he/she advised a change.

Your genotype showed some mutations even when the viral load was low, below detection. Remember that the virus replicates 10 billion times daily in a highly error-prone fashion, such that many mutations occur regularly; there are called 'polymorphisms.'

What your doctor is looking for with a genotypic resistance test at a time of high viral load is a new majority population of resistant virus that is overgrowing wild type and causing your regimen to fail.

We have found that resistance tests taken even when a person's viral load is < 5 copies/ml may show some resistance mutations, for the reasons above. We don't know what significance these will have in the long run, i.e. they may just be polymorphisms that have no clinical consequences.

Finally, its not surprising to see some disagreement among your doctors with this data. A more agressive approach would be to try to stay ahead of the virus with rapid regimen changes when mutations are observed that MAY lead to virologic failure.

A more conservative approach would be to maintain a regimen that is working and is well tolerated because the next one might have side effects that are difficult for you, and your current regimen MAY be able to handle these mutations, especially if they are polymorphisms rather than the mutations of a growing dominant population of virus. This position now seems more likely, given your experience of the last 6 months.

While you are entitled to seek as many opinions as you want, you can see that it doesn't always result in complete agreement. Perhaps you can pick the physician whose opinion you trust the most, discuss all of these opinions with him/her, and then follow their recommendation.

I have added the website at which to access the IAS-USA guidelines on resistance for further information.

Achieving undetectable
Trizivir resistance

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