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Salvage Regimen
Aug 14, 2004

I've got some resistance and need to pick a new regimen. RT: 67N 70R 184V 219Q 333E 103N 106I PI: 10I 30N 36I 71T 88D Drug history: AZT, d4T, AZT/3TC; at this point I added IDV, which reduced my VL from 300K to <400 over about a year; swapped NFV for IDV due to kidney stones and within a year VL was up to 30K; tried ddI/d4T/HU for a while, VL stayed under 10K; switched to EFV/ABC/adevofir/3TC/HU and was <40 within 4 months; almost immediately became detectable, but never more than a few hundred copies; went back to the ddI/d4T/HU to avoid accumulating resistance; quit that in 2002 due to incipient neuropathy. So... I think that since the IDV suppressed my virus, with little or no help from the AZT/3TC, with which I had prior experience, I probably don't have much PI resistance other than the 30N mutation that shows up on my tests. This would account for the NFV failure. In a similar way, the fact that I was suppressed or had low viral loads on EFV/ABC/adefovir/3TC/HU even though I have 103N indicates that I probably don't have much nuke resistance other than the 67N/70R/219Q TAM pattern. Otherwise, what's suppressing the virus if the EFV is knocked out by the 103N? This leads me to a combination that includes a PI, obviously, and maybe TDF. I'm thinking either LPV/r/TDF/AZT/3TC/T20 or LPV/r/SQV/T20. The AZT/3TC in the first possible regimen is there because my doctor believes it will prevent K65R and keep the TDF active. Any thoughts or suggestions you have would be greatly appreciated.

Response from Dr. Henry

You don't mention what your current CD4/RNA levels are or what your lowest CD4 count and highest RNA levels is and whether you have had any AIDS related complications. Those details and many others influence the intensity of what I might consider for individual patients. If there is some resistance to all 3 classes as you describe it is a challenge to durably suppress viral replication and more difficult if the CD4 is low and HIV RNA levels are high. In general I would go with 2 boosted PIs (possibly checking levels), a reasonable 2-3 NRTI backbone and T20 in situations where the risk for clinical complications is high (CD4 < 200). KH



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