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Resistance in Long-Term Treatment Naive Patients
Mar 16, 2008

I recently tested positive for HIV, but I know for sure that the infection took place in 1993. My doctor said it is highly unusual for someone to go that long having HIV without getting sick (I am sick now, and have been for about 2 months). I am going to see an infectious disease specialist next week. My question is this: Do you think it is likely that I have developed resistance to any of the HIV drugs just by waiting so long to get treated? Can resistance develop in totally treatment-naive persons infected for long periods of time? Since I was infected in 1993, that was before protease inhibitors or non-nukes were even in use, so could my HIV be resistant to those drugs? Would a person like me need a resistance test before beginning ART?

Response from Dr. Sherer

Everyone with HIV infection in the US, and everyone in a setting where 5% or more of untreated patients have been shown to have acquired a strain of HIV with one or more drug resistance mutations, should have a resistance test before ART is prescribed, including you.

I do not share your confidence that you know the year in which you were infected with HIV, but I am sure that you have reasons for believing that to be true. Even if this were true, it is possible that you could have acquired a virus with one or more drug resistance mutations to drugs that were commonly in use at that time, i.e. the nucleosides.

If you acquired a wild type virus in 1993 or since then, you may well have polymorphisms that include single mutations that might be associated with resistance, for example, to 3TC at the 184 locus, but it is not possible to 'evolve' drug resistance in the absence of the selective pressure that is imposed by ART. So, no, you can't just develop resistance to ART by having had untreated HIV infection for a long period of time. And, specifically, you could not have HIV that is resistant to the classes of drugs that you mention, the NNRTIs or the PIs.

However, since it is very difficult to know precisely when you did acquire the virus, and since it is also possible that you were infected more recently, or, to consider yet another possibility, it is possible that you first acquired the infection in 1993 and then acquired a second strain via superinfection more recently, I would still strongly recommend that you and your doctor follow the current standard of care in the US and obtain a resistance test prior to treatment, so that you can determine the best regimen for you now with three drugs, all of which will work effectively.

I suggest that you take your concerns and these responses to your first doctor visit with you.

I will suggest that you and your doctor also talk about the following questions. Why are you so confident that you were infected in 1993? Can you defend that belief? Do you really mean that you have had zero risk of HIV for the past 15 years? While that is possible, it is uncommon, in my experience.

If you did think you were infected 15 years ago, was your recent test the first time you were HIV tested since then? Why did you wait so long to be HIV tested? Or if you knew that you were HIV positive long ago, why did it take you so long to get into care and get your CD4 cell and viral load tests?

Knowing that HIV doctors are working hard to encourage people to get tested earlier, before they become sick, how did it happen that you became sick before ever starting ART?

Your questions concern me greatly. They suggest more than a little knowledge of HIV, but to date, your knowledge has not served you well. I hope that you and your doctor can prevent any unnecessary delays and lapses in your care, and that you can regain your health promptly under his or her care. I urge you to listen carefully to your doctor, and not make guesses about how HIV works at this critical time for your health. You can't afford to do that any more.

Stopping Fuzeon to Save Fuzeon
I missed 2 doses

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