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Is treatment failure inevitable?
Aug 8, 2005

I've been on Sustiva and Combivir for almost 7 years now. I've been undetectable for almost the whole time, with the rare "blip". I take my meds religiously and have no side effects to speak of either. Is it inevitable that my regimen will fail if I continue my run of good luck? I've read up on this and there doesn't seem to be a definitive answer.

Response from Dr. Sherer

While I appreciate the faith you show in this website to provide a definite answer where no one else seems able to, I fear that I will disappoint this expectation.

The best evidence that resistance is not inevitable is your own case report, and many, many others like yours, of long term success on the same regimen for 5-10 years or more. Your best action is to continue your excellent record of adherence.

Most HIV physicians also have experience with patients who report the same faithfulness with the same regimen, only to experience virologic failure and resistance after months or years.

We have good evidence that virus evolution, with the development of resistance mutations, continues in the bloodstream and in 'sequestered sites' in the body such as the gonads and the central nervous system, even in patients with undetectable viral loads by standard viral load assays.

However, in spite of this evidence, we have many instances of prolonged successful suppression, like your case. Apparently ongoing evolution as I've described it does not inevitably lead to clinically significant viremia, resistance, and virologic failure. It may be that the low level development of resistant clones is adequately managed in some people by one or two of the active drugs in an active three drug regimen, in spite of the resistance to one of the drugs, as well as their immune system.

Neither I nor your doctors are fortune tellers, as we often remind our patients. We do our best to help patients understand what the possibilities are when they start ART, and what options they have in the event of treatment success and treatment failure.

For seven years, you have had the best possible outcome from one regimen. I will hazard this guess - this is the first regimen you've ever taken. Most of the prolonged positive outcomes come on the very first regimen, which is why HIV clinicians spend so much time trying to ensure that the precious opportunity of the first ART regimen is used to its fullest advantage.

There is no theoretical reason why you shouldn't expect another 7 years or more of success with the same regimen, in view of your experience. Keep up the great work with your adherence, and let us know every once in a while how things are going. Your story is an inspiration to people living with HIV and their caretakers everywhere.


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