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HIV Drug ResistanceHIV Drug Resistance
           
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2 Days Missed
Sep 13, 2008

I was diagnoised with AIDS in December of 2007 with PCP and a CD4 count of 32. I began ART with Atripula and Bactrim, and have had favorable results. My most recent CD4 was > 300, and viral load undetectable. I take my medicine every night at bedtime, which may vary, but usually within a 2-3 hour window. There have been one or two incidents that I recall where I fell asleep and forgot to take the meds so I took it the next morning. I'm writing at this time because this morning I woke up and realized that I had not taken my meds last night and when I went to take them, I then discovered that I had missed the previous day's dosage as well. Needless to say, I am somewhat alarmed in that I may have undermined my treatment and be viable for drug resistance. Should I be worried about resistance at this time?

Response from Dr. Sherer

Yes, you have reasons to be concerned, but NOT to panic. You should arrange to see your doctor in the near future, e.g. this month, and get another viral load test. If it is elevated, your doctor can obtain a genotype to see resistance has developed.

There are good reasons to be hopeful that this single lapse may not have led to the development of resistance. In an important trial of intermittent treatment, it was observed that treatment for one week on drug, followed by one week off of drug, in patients in whom full viral suppression was achieved, there was very few episodes of viremia. Similarly, an ongoing trial in Boston is testing whether, in the same population of people with excellent viral load suppression, weekend holidays from meds for 2 days and full ART treatment for 5 days on a regular basis (the FOTO trial, for Five On and Two Off) are as good as continued daily ART. When this data were last presented, the FOTO group had results that were comparable to the full treatment group.

It appears that, once people who have achieved full viral suppression on ART with viral loads below detection for 3 months or more, a return to full viral activity is delayed for a short period if and when their meds are temporarily interrupted. That delay appears to take 5-7 days.

Unfortunately, these are research observations only, and they are not definitive. Most clinicians are aware of anecdotes in which a patient missed only one or two consecutive doses of meds, as you did, and they DID develop resistance, so there are no guarantees here.

As above - don't panic, the chances are good that resistance will not have occurred, and see your doctor promptly for repeat testing. More importantly, talk to your doctor about how to prevent such lapses in future.


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