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HIV Drug ResistanceHIV Drug Resistance
          
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Was my premature?
Sep 13, 2008

My viral load dropped 99.99% according to my doc. There was a "log 5" decrease and the numbers went from 400,000 to 1500 a 2 weeks ago when I just started treatment Cd4 increase was 16 to 64. Needless to say, I am relieved and partially thrilled with the ressult of the meds: prezista/norvir,, intelence, isentress. My doctor said he had never seen such a decrease like this before. At this point, I'm tolerating them pretty well. My question is that since this treatment is not recommended for treatment naive patients, but for those who have developed resistance, have I been put on these drugs prematurely? What does it mean for the future use of other drugs should I need them? My doctor in NYC, after consulting with 2 other HIV specialists thought it best to put me on these meds. In fact, he said they all agreed. This was due to such a low tcell count, and sexual history. Crystal Meth strikes again! He thought there was a good chance that I had possibly already been exposed to resistant strains and they all felt that, with that CD4 count and the long wait to get the resistance test back. I'm anxiously await that result.

Am I "overthinking" this? Was my doctor wrong? He has a great deal of experience with this and I really trust him.

I look forward to hearing from you.

Response from Dr. Sherer

These are the questions that you will have to take up with your doctor and his consultants. I would add to that the question of what you will do when you receive the resistance test results. Will you and he change the regimen based on the resistance test?

I gather from your question that you were started on medication before the result of the resistance test was available. Your doctors were motivated to start you right away by your very low CD4 cell count. Apparently, your doctors were also motivated by your history to use 4 drugs, though there has never been a clinical trial among treatment naive patients showing that 4 active drugs was superior to 3. And, as you suggest, your doctors decided to use a novel initial regimen.

There are available data for the use of Prezista/RTV in naive patients; in a recent head to head trial comparing it to lopinavir/r (Kaletra), it was found to be comparable, and the recent IAS-USA guidelines includes it among the acceptable initial boosted PIs.

The use of a second line NNRTI (Intelence) as well as the new integrase inhibitor raltegravir (RAL-Isentress), is outside of current guidelines as well, as you suggest. There are data from one trial of RAL in comparison to EFV (Sustiva) in which it was found to be comparable over 96 weeks, but there is uncertaintly about the use of RAL in treatment naive patients at present.

The main reason for any uncertainty for the choice of ART in naive patients is that our standard regimens perform extremely well, i.e. a boosted PI such as lopinavir or atazanavir, or EFV, have been shown to lead to optimal control in 80%+ of patients in one year, and the majority of patients after 3-5 years or more.

My guess is that your physicians thought that your risk of an acquited NNRTI mutation was very high, and, presumably, that your risk of one or more PI mutations was similarly higher than usual.

You and your doctors have many options from this point forward. When your doctors get your resistance tests back, you can discuss whether this unusual initial regimen remains the best option for you. While I understand your enthusiasm for your rapidly falling viral load, you should be cautioned that similar results are seen in patients with advanced disease and viral loads below 100 with our current standard regimens, though they may take a little longer to occur.

You should also talk to your doctor about your use of crystal meth, as that represents a serious threat to your medication adherence in the long run.


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