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HIV Drug ResistanceHIV Drug Resistance
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Am I really resistant?
Oct 22, 2006

Hello, Reading your responses about resistance has brought me to the following question. I was diagnosed in 2001 when i fell pregnant and was put on Combivir alone. VL was 85,000 and CD4 count around 250. 3 months later VL was 9,000 and CD4 count around 300. 3 months later VL still 9,000 and don't remember CD4 count. My doctor then put me on Zerit, Videx and stocrin cos he said I had become resistant. Was he correct in making this decision? I achieved undetectable VL on the new regimen but developed PN. At the time CD4 count was 600. I relocated to another town and got a new Doc who stopped my meds cos I had severe PN. After a year I re started on stocrin and kaletra (4BD). This was Nov 2003. VL undetectable after 3 moths and a steady rise in CD4 count. However in Nov 2005, VL rose to about 1,000 and CD4 count increased to 700. Next test in Sep 2006 ( 1 year later) VL 2,900 CD4 count 975. What is happening here? Considering I did not really fail Zerit/Videx/stocrin froma virologic point of view, what else is available to me? Can I still check if I'm really resistant to combivir even though I took it 5 years ago? Most of all I'm concerned about the rise in VL from undetectable and given my treatment history, is there hope for me? Thank you

Response from Dr. Sherer

Yes, there is hope for you. You have had good benefit from ART, in so far as your CD4 cells are high now, i.e. 975 cells from a baseline of 250 cells. You and your doctor can take the time to assess your situation, obtain a resistance test, and make the best decision about your next regimen. I can offer some suggestions, but I lack some important information that your doctor has in order to make the best suggestion for your treatment from this point forward.

There are some elements in your history that concern me. If you really did not see a doctor and had no CD4 cell count from Nov 2005 to Sep 2006, for example, that is a problem. You should see a doctor at a minimum of once monthly for a while, and if you achieve a good outcome, at most once every two months. Long periods without a medical visit and without CD4 and viral load testing are a bad idea.

In 2001, the standard of care for a pregnant woman with a CD4 cell count of 250 was a three drug regimen, not combivir alone. I would not expect you to have acheived virologic control with combivir, and you did not. After six months, you likely had some resistance to both 3TC and AZT, so the switch to stocrin + DDI + D4T was not a switch to 3 new drugs to which you were completely susceptible.

Nonetheless, you became undetectable for a while, and you had a good CD4 response, with a rise up to 600 cells/ml. However, you experienced peripheral neuropathy, as did one third of patients who were on D4T + DDI.

The switch to a new doctor at that time was a good idea, and after one year off ART you started an NRTI-sparing regimen of LPV/r (Kaletra) and EFV (Stocrin)in Nov 2003. This raises another question: Did you take the year off on your own, or at your doctor's advice? My advice is to work with your doctor on important clinical decisions like stopping medications in future, and not to do so on your own.

You are correct to be concerned that you may have some resistance mutations. You and your doctor should do a resistance test while you are still taking EFV + LPV/r, so that he or she can see whether or not you have resistance mutations to either drug.

There are many options still available to you. The newer NRTIs, for example, such as tenofovir and abacavir, have activity in a person who has some resistance to NRTIs (like combivir). It is unlikely that you are completely resistance to LPV/r, if you have taken the medications faithfully without breaks in your adherence, and so this drug is likely to still be active for you.

There are also newer PIs such as darunavir and tipranavir that may be available to you, depending on where you live.

And finally, in future new drugs and targets are likely to be available for someone who has developed resistance to all current drugs, though this is not your status at present.

I urge you to see our doctor monthly, get a repeat viral load and CD4 cell count, as well as a resistance test, review your complete treatment history, responses, and toxicity history, and make some rational decisions about your treatment with your doctor, and I urge you to show him or her this email.

why undetectable without meds?
Change of Regimen

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