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Adherence
Jul 6, 2003

How long do the antiretrovirals keep you healthy for? I am 22 years old and was infected 4 years ago which was my exposure. I have not had any bloodwork done yet but am going to do so next week with an hiv specialist. If I adhere to my meds what do you expect my survival would be...a normal lifespan?...what therapies are in the pipeline in case the current regimens fail?

Response from Dr. Cohen

We've got lotsa reasons for optimism for those starting therapy these days. Not only were meds pretty potent - they're in the past year maintaining that potency and improving our track record on how well people can feel while on them. Since it was not only a problem of controlling HIV - but also a problem of doing so with combinations that are easy enough to do, and something people can feel well on when taking. And in these past few years we have been increasingly reassured that we can make progress on all three goals at the same time. Meaning combinations that work, that are easy to take, and have few side effects both initially and over time. While no one would want to claim our meds are perfect and worry-free - we are certainly doing better now than we were even just a few short years ago on all of these criteria.

As for planning for a pipeline of what to do next after your first combo - it seems increasingly likely that we can do well on the first combination - so much so, that we don't often focus on the second combination when planning our first. Certainly not as much as we used to. Nonetheless we've got about three solid turns at bat with current combinations - and more to come. So whatever you do start on - and if for some reason it doesn't last forever - we do have options. And as a result - there are a few competing ways that are attractive and successful when starting - and virtually no matter where you do start, there is a plan B that can work.

Now, there can be a few wrinkles. One is that I'm assuming the HIV is caught is sensitive to all of our meds. However perhaps 5% - or more - do acquire a strain of HIV that is already resistant to some of the medications we'd use - which means there are far fewer choices - it could be as if you had taken a few combinations already... and for that reason we sometimes do a test to see if there is any evidence of resistance before starting. You might ask if that is a consideration for you. Clinicians do vary however in how much they find such testing helpful, and since you were infected 4 years ago, the test is less helpful than for those whose infection is more recent. This is because over time, the more sensitive "wild type" strain of HIV tends to overgrow any resistant strains you were exposed to - and so some clinicians just don't find testing at this point all that helpful. But some do - and this is one consideration in treatment planning.

One more point. Whatever you do start on might work very well. Or there may be a side effect. Perhaps as many as 5% cannot tolerate any of the frequently used meds. And we cannot predict who is in this 5%. However, if you have a good relationship with your specialist - you can often substitute one med for another - and maintain control against HIV, without losing any medications to resistance. This is worth planning - just in case of side effects - since avoiding resistance is among the best ways to ensure a long and successful treatment plan.

And the best way to avoid resistance - simply - is to find a combination of meds that are active against your strain of HIV - and then take these meds as needed each day. Since HIV wants to win - and maintaining ample blood levels of these meds by taking them as required each day is the single biggest issue we face when defining the difference of why combinations work -- and why they didn't.... which doesn't mean you should feel miserable when on meds - as I said, we might be able to change combo ABC with combo ABE --but daily med taking is often the critical factor in ensuring the success of whatever meds you are on.

Hope that helps. Let us know if there's more to do.



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