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Sustiva And Epzicom
Jan 23, 2006

Hello and thank you all for your wonderful insight. I have been on Sustiva and Epzicom for almost two months. At the start, my Viral Load was 500,000, and CD4 180. I was very weak and tired, basically felt like crap. My CD4 is now 340 but my Viral Load did not change much. I feel 100% better than I did at the start of therapy though. My adherence to the medication has been total; I never missed a dose. My doctor said he expected me to be undetectable by now. I expressed some concern to him that I don't believe my blood products were handled properly through the state lab were I received free blood testing. He just kind of raised his eyebrows and ordered another Viral Load to be drawn. The only other thing that concerned him a bit was when I first started the medication I took a Sustiva the first night, but not the Epzicom because the pharmacy was out of it at the time. The very next night though I began taking both medications and have been religiously ever since. Just wondered what your thoughts were on this type of situation. Thanks again and good luck to you all!

Response from Dr. Sherer

In general, the first months of ART are the most difficult for several reasons, and you've had a couple of them. First, it may take some time to feel better - but fortunately now you do. Next, the period of watching the response to ART is inevitably anxiety producing, particularly if it takes a longer time than you might have hoped.

You mentioned that your viral load was 500,000 copies/ml. You might ask your doctor if this was the reported value (compared to 512,848). Some viral load tests have a ceiling of 500,000, i.e. 500,000 is the highest reported value, so it's possible that your actual value was much higher.

Your viral load and CD4 cell count at the start of ART would lead me to predict that you would take longer than many to achieve a viral load below detection, eg 3-6 months, so I'm not surprised that this is the case. There is good evidence that the higher the baseline viral load, the longer the time to undetectability. You didn't mention the last viral load value, but I would not be concerned unless it showed a less than 0.5-1 log decline since that start of ART.

Finally, we advise patients ALWAYS to take the medications as directed for a reason, and one is to avoid your experience, i.e. taking only one of three drugs in the regimen.

Since efavirenz is very susceptible to resistance, and since only a single amino acid mutation can cause resistance, we advise never to use it alone. So unfortunately you are right to be concerned about that single lapse.

Nonetheless, you should be reassured for several reasons. Sustiva-containing regimens have been shown to be remarkably resilient in general, in spite of this vulnerability to resistance, and nothing in the evidence you have presented to date suggests that you are having a less than optimal response. So patiently await your next values and do your very best to stay adherent - this is the best you can do. And of course I urge you to talk to your doctor about these concerns.

Short question on drug resistance
Adherence question.

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