My husband has been on Trizivir since Sept. 2001. For the past 2 years his viral load has been approx. 2,000 and his cd4 count around 425. Should he change medicine? Is it bad that his viral load is not undetectable even though his cd4 is not decreasing? His doctor always says that everything is fine and he doesn't need to change meds, but I am not confident in that. Please respond quickly, his next appointment with her is in 3 days! Thank you .

Concerned wife

In general, three nucleoside (or NRTI) combinations have fallen out of favor, following inferior clinical outcomes to regimens with 2 NRTIs and either a PI or an NNRTI. In the clinical studies of your husband's drug Trizivir, patients who did the best tended to have baseline viral loads that were lower, e.g. < 100,000 copies/ml, and to have higher baseline CD4 cell counts. However, that was not always the case, and the current HHS GUidelines suggest that one should use this regimen only when other regimens cannot or should not be used.

Still, some clinicians, like your husband's physicians, have chosen to keep patients who were doing well on this regimen alone, rather than switching or intensifying by adding an additional drug.

I sugggest that you and your husband ask this question of his physician, and take these suggestions with you. It might be useful to know what your husband's CD4 cell count and percentage were, as well as his viral load, when he started this regimen, as well as his lowest CD4 cell count and highest ever viral load.

It would also be useful to know if your husband's physician has obtained a resistance test, and, if so, did the results suggest that his low level viremia for two years was associated with the gradual development of NRTI resistance mutations that might compromise his response to a second regimen.

In one clinical study in patients who, like your husband, had low level viremia on this combination for a year, half of them had resitance to 3TC (lamivudine) alone, and half had additional resistance mutations to the other NRTIs. So whether or not there has been some new resistance is a question that can be answered with a genotype test, which I recommend to your husband and his physician.

I regret that this answer did not arrive in time for his last appointment, but I encourage you to talk to his physician at your next opportunity about this response, and the issues raised.