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HIV Drug ResistanceHIV Drug Resistance
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Aug 28, 2006

I went from 2 cd4 and 100,000 VL to 167 cd4 and UNDETECTABLE VL! I have been switched to Atripla, and I am praying that it was a good move. Is there anything you recommend to do besides the obvious (adherence, safe practices etc) to remain undetectable? Anything that will raise the CD4?

Response from Dr. Sherer

There is good evidence that 'Atripla', which is the new one pill once daily pill that contains co-formulated efavirenz (Sustiva), emtricitabine (FTC), and tenofovir (TDF), has the same pharmacokinetics as each drug individually, and as efavirenz plus truvada (which in turn is co-forumulated tenofovir and emtricitabine), so there are no reasons to think that your excellent response will change, as long as you are adherent to this regimen.

There is strong evidence that adequate nutritional support and ART are superior to elevating the CD4 cells compared to ART alone from studies conducted in the developing world such as India and Uganda. Whether the same outcomes can be expected in the developed world is uncertain, but most clinicians believe that optimal nutrition is essential to the best possible immunologic response.

Since intercurrent infections are known to evelate the viral load and to increase immune activation, which can increase the number of targets among CD4 cells, macrophages, and other immune cells, it is reasonable to include regular physician visits and prompt treatment of infections and other conditions that are associated with immune activitation as part of the list of essential activities to improve the response to ART.

Finally, most HIV clinicians will also discourage people living with HIV on ART from heavy use of drugs or alcohol, for several reasons. Regarding ART outcomes, these activities may decrease adherence and lead to missed doses. Regarding HIV transmission, these practices are associated with disinhibition and a greater likelihood of unsafe sexual and drug use behaviors. Finally, there is some evidence that prolonged chronic alcohol and drug use have deleterious effects on the immune system and other key organ systems; for example, alcohol is a liver toxin, and its use may aggravate common HIV co-morbidities such as hepatitis B and/or C.

It is also useful to keep your list of responsibilities simple. Take your Atripla tablet every day with no misses, and work very hard to create your own internal mechansisms to prevent even a single lapse. Ask you friends and family for help with reminders, for example. Store your medications in one safe place, and establish an iron clad routine for taking your medications at the same time every day, including weekends. You may want to store a few doses of your medication in additional locations, such as at work (in a safe place), in a car, at a friend's or family member's house, all in order to prevent a single missed dose.

This is the single most important responsibility to act on, and the most likely to lead to higher CD4 cells (as it has already done), improved quality of life, and prolonged life.

And, of course, keep your doctor visits, and share this email exchange with him or her.

Viral load still not undetectable
conflicting resistance tests

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