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Failing Regimen
Nov 21, 2004

Hello Dr. Sherer, I have been on my second regimen (Sustiva/Trizivir) for about 3 years now. It has been an unusual journey - some months my VL is <50, some months it can go up to 350 or even 780, then back down. I am 100% adherent. My dr. is afraid to alter the regimen until a resistance test can be performed - but so far, the VL has not reached 1000. He says he doesn't want to make a guess before that time and end up causing more resistance. Do you think this is a good idea? As background my first regimen was Viracept, Zerit and Epivir. I was on that regimen for 5 or 6 years and it kept the VL <50 until near the end. Thanks! Alex

Response from Dr. Sherer

If you have only had single 'blips' of viral loads between 50 and 1,000, and returned to <50 thereafter, the evidence suggests that you are not at greater risk of viral failure and the development of resistance. I would advise you to continue your fine adherence and monitor your viral load closely with your doctor, as you are doing. You didn't mention your CD4 cell count, which would also be a consideration in the urgency of this matter.

You also didn't mention whether you had a resistance test at the time of your first regimen failure, and what it showed. That information would be useful in these deliberations, if available, particularly whether you had either the M184V mutation (3TC resistance) or thymidine analogue mutations (TAMs), suggesting a compromise of both stavudine and zidovudine resistance.

You and your doctor do have the option of submitting a viral load of 500 - 1,000 for genotyping, as on some occassions it will yield a positive result.

Finally, your doctor is correct to seek the results of a genotype in the event of real viral load failure (if and when that occurs, though as I said above there is no reason to think that you are at an increased risk of that occurrence at this time, if the above circumstances are true). The important information to be learned will be the state of the NRTI backbone resistance in that event, as well as the nature of the NNRTI resistance. We know from trizivir study data that the development of TAMS takes more than 1-2 months in the majority of patients, so you and he or she are likely to have the time to make an informed decision.

Of course I urge you to discuss these matters with your doctor.

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