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Drug Resistance
Jul 9, 2009

Kindly find my result for HIV drug resistance, kindly advice what should I use? Consider i dont have specialists in HIV in my country

Integrase Inhibitors Raltegravir (Isentress) no evidence of resistance

Non-nucleoside Reverse Transcriptase Inhibitors Delavirdine (Rescriptor) resistance Efavirenz (Sustiva) resistance Etravirine (TMC125) (Intelence) no evidence of resistance Nevirapine (Viramune) resistance

Nucleoside Reverse Transcriptase Inhibitors Abacavir (Ziagen) resistance Didanosine (Videx, Videx EC) resistance Emtricitabine (Emtriva) resistance Lamivudine (Epivir) resistance Stavudine (Zerit) resistance Tenofovir (Viread) possible resistance Zidovudine (Retrovir) resistance

Protease Inhibitors Amprenavir (Agenerase) resistance Atazanavir (Reyataz) resistance Darunavir (Prezista) no evidence of resistance Fosamprenavir (Lexiva) resistance Indinavir (Crixivan) resistance Lopinavir/Ritonavir (Kaletra) no evidence of resistance Nelfinavir (Viracept) resistance Saquinavir mesylate (Invirase) resistance Tipranavir (Aptivus) no evidence of resistance

herunder the drugs i have been taking for 12 years

Atripla (efavirenz + tenofovir + emtricitabine) Combivir (zidovudine + lamivudine, AZT + 3TC) Videx (didanosine, ddI) Crixivan (indinavir, IDV) Invirase (saquinavir, SQV) Norvir (ritonavir, RTV) Viracept (nelfinavir, NFV) Last CD4:180 copies Viralload: 9500

Response from Dr. Sherer

It's not possible for me to recommend a specific regimen for you in this format, but I can make some general suggestions based on the information you have provided. I would urge you to continue to look for an HIV doctor with some experience in treating patients with drug resistant virus, as your care would benefit from the ongoing attention of a physician with that expertise.

With that doctor, it would be useful to review the exact resistance mutations that led to the determinations of 'resistance or no resistance' in your description, and to review the order of previous regimens, and the viral load and CD4 cell results with each treatment, as well as any side effects and other adverse reactions to the drugs, and other treatments and OIs presently or in the past.

It would also be useful to repeat the viral load and resistance test with both a genotype and phenotype test, if possible.

Let me also note that it is clear that the HIV medications are still helping you, in spite of the lack of complete viral suppression, and you should still be on treatment. Whether or not a change in treatment is necessary or desirable at this time is difficult to say with certainty, given your history. It is possible, given your information, that you could receive a regimen that would fully suppress your virus to undetectable levels and raise your CD4 cells. I don't have enough information, however, to say whether that is a likely occurrence with a change in regimen.

Having said that, the drugs that appear to be available for use include: NRTIs: tenofovir (possibly) and lamivudine or emtricabine NNRTIs: etravirine (possibly) PIs: lopinavir, tipranavir, and darunavir

And ralegravir, miraviroc (possibly), and enfurvitide (possibly).

Individuals in your position in the early access programs for etravirine and raltegravir have had fairly good success with a regimen that relies on raltegravir as the anchor drug, in addition to 2 or more other active drugs. In you case such a regimen might be: 1) RAL + LPV/r or DRV/RTV + TDF + 3TC, or 2) RAL + ETR + TDF + 3TC, or 3) RAL + LPV/r or DRV/RTV + ETR + TDF + 3TC

Among these options, I would favor #3 to give you the best chance for full suppression, if all of the drugs are available to you. The choice of PIs would depend on the exact resistance mutations of your virus; if you are, as you suggest, fully susceptible to both lopinavir and darunavir, I would advise using lopinavir, which could allow for a later use of darunavir.

In addition, you and your doctor could consider adding enfurvitide, if that drug is available in your country. And you could consider obtaining a tropism assay to determine whether your virus is R5 tropic, in which case miraviroc could be used (if it is available). If, on the other hand, your virus is X4 tropic, you would not benefit from the use of miraviroc.

Again, please understand that I can't recommend ANY of these options to you directly, because I lack too much information that might lead me a different conclusion. Your care is complex, and you need the best judgment of a knowledgable HIV expert to help with this stage of your care. I encourage you to take your questions and these suggestions with you to your next doctor visit, and to ask your doctor to refer you or to seek the assistance of an HIV expert in your region.

Resitant to all PIs & almost all NRTIs
Darunavir Cross Resistance

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