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Switched to Truvada from Combivir -- viral rebound
Oct 30, 2005

Hello Dr Conway,

My Fiancée who is 42 yrs old African American, found out 13 yrs ago that she was HIV positive. She started meds 4 yrs ago, taking Combivir & Sustiva until 4 mths ago when she switched to Truvada & Sustiva, because of muscle & fat loss in some areas of her body.

Prior to the switch, her CD4s fluctuated between 400 & 600 with an undetectable viral load. Other blood tests taken at her quarterly screening for the duration prior to the switch were normal.

Her first screening 2 mths after the switch, revealed a CD4 count of 800, however, the viral load was at 50 copies. Her second screening 4 mths after the switch, revealed a CD4 count of 700, however, the viral load was at 70 copies. I am concerned about this trend.

Since the switch, her body shape, for example, hips, butt, and legs, have made a remarkable comeback. Her feminine body contour has returned. I also observed, what appeared to be hyper-pigmentation/darkening on the soles of her feet and palms to be clearing up. She does not complain of any issues since the switch.

Below are my questions:

1) Is the increasing viral load something we should worry about? If so, at what figure should we be concerned?

2) She is approx. 160 Lbs. What is the amount of Truvada she should be taking based on her body weight? My thought is she may not be getting the required level of the drug in her system to ensure viral suppression...

3) Will a strategy of using (twice/day) FTC + Tenfovir along with Sustiva, give a higher level of the drug in her body? My thought is, when FTC + Tenfovir is combined to make Truvada, some of the individual drug strength may be lost

4) Are what appear to be sunken eyes in the eye sockets, an indication of disease progression?

5) She has been taking Dr Kaisers Kpax vitamins. What is your take on that?

6) I have read conflicting reports/views on the lifespan of an HIV positive person. Some say 10 to12 yrs without meds; 20 + yrs with meds; some say a normal lifespan with meds & complementary careproper diet, exercise, dietary supplements, and proper rest & relaxation. In your opinion, what is the life expectancy of someone who is HIV positive and doing ever thing possible to suppress the virus & combating side effects due to meds with success?

7) In the question above, what if the person is struggling to keep HIV suppress, and is also having side effect issues from the meds?

I have asked a lot, could you also please point me in any direction where I can see research documentation on successful living with HIV?

Response from Dr. Conway

1) At this stage, I would not be terribly concerned about the viral load, but I would make sure that adherence to therapy is not an issue, and I would monitor the viral load on a monthly basis to make sure these are just "blips" and do not represent true virologic breakthrough. I am not concerned any more deeply until the viral load is 5,000 - 10,000 or higher. If this occurs, I would immediately order a resistance test to help guide the next choice in therapy.

2) The components of Truvada (tenofovir and emtricitabine) have extremely high levels in the cell (where thet are active) and very long half lives, so taking them at the standard dose produces much more active drug than she actually needs, and it stays around in the cell longer than it is needed. In fact, the emtricitabine part of the Truvada is better than the lamivudine part of the Combivir in this respect.

3) There is absolutely no rationale to give any part of Truvada twice a day ot enhance its efficacy.

4) At this CD4 count, it would be hard to imagine how the sunken eyes could be a sign of disease progression.

5) There is nothing bad about Dr Kaisers Kpax vitamins, which are purported on various websites to boost the immune system. Although their content is not completely divulged, they do not appear to contain anything that would be deleterious to her health...and they may help!!!

6) My current feeling is that is likely that a person who is able to achieve a full virologic response in this day and age may well live out their normal life span.

7) The key to success is obviously to design a regimen the person can take, will produce virologic suppression and avoid side effects. Given all the choices of medications available to us today, the key to achieving this goal is often communication between the infected person and her caregiver to do the "fine tuning" of a regimen that may be needed to meet the stated goal.



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