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Do I understand it correctly?
Jul 10, 2007

Dear Doc,

First my compliments for your work here!

Now my question: I am told that nowadays when you're adherent to medication it takes years before resistance occurs to the regimen you're on. When that happens it's time to switch to another combination until, after years, again resistance occurs. Based on this principle newly diagnosed can have an outlook on (near) normal life expectancy.

Is this correct or is this a rosier explanation of the nowadays reality?

I'd be glad to read your response.

greetings from the Netherlands from a 38yo guy

Response from Dr. Sherer

The picture is not as 'rosy' as you suggest, but there are many positive items to take note of.

For a 38 year old like yourself, for example, who is found to have HIV, who gets onto a highly suppressive ART regimen, who faithfully adheres to the medication, AND who is among the >75% who have a positive response to the medication, it is estimated that a normal life expectancy is highly possible.

That is the good news, and note that it depends on several contingencies all going the right way.

The bad news is that sometimes, e.g. for 10-20% of people who start ART, there is trouble, either as significant side effects or failure to achieve full suppression and rapid development of resistance. One emerging problem is that more people - around 10% in the US - are acquiring a strain of HIV that already has one or more resistance mutation, and so may have a less robust response to a regimen, if that mutation has not been identified and the patient's regimen has not been chosen by a physician with the knowledge of the mutation. For this reason, current guidelines recommend that all HIV positive patients have a genotypic resistance test before they are treated.

Another potential problem is that even short term lapses in adherence, which are common, particularly in the first year of ART, can lead to drug resistance and treatment failure. This is thought to be the most common cause of treatment failure.

Now to your second point. It is true that there are several excellent options for ART, and that we expect a second and even third line ART regimen to be fully suppressive for prolonged periods of time. That is the good news about multiple treatment options. However, it is also true that the first ART regimen has the best chance for long term viral suppression and durability, and that the chances for this diminish with each successive regimen. For these reasons, it is best for the person living with HIV and their doctor to take the time needed BEFORE treatment it begun to ensure that the very best possible adherence to the medication is acheived, as well as to ensure that the person with HIV is able to tolerate the side effects (if any) that are associated with the regimen. We call this establishing 'readiness' to start ART.

The first 6 months on ART are particularly fragile, and a good time for frequent visits with the doctor to ensure that all is well with the ART regimen, in order to ensure the longest possible durability of that first regimen, or to detect as early as possible when side effects might be a problem with a given regimen.


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