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To Blip Or Not Blip - I"m Baaack
Jul 6, 2003

Hey Doctor Cohen,

I'm back again. I wrote you in January about a VL blip and titled the question "To Blip Or Not To Blip." Well, I'm back. I just got my new VL results and I'm at 1010. I'm going in tomorrow to send off a sample for geno-type. I also have a new doctor because of my insurance. He gave me a prescription last week for Viread prior to getting my VL results. He did so based on recent failure data with Trizivir (my current regimen). I've been on Trizivir for 3 and 1/2 years with my mutation profile. I decided to wait until I got my VL results before deciding to fill the Viread. When I got my results today and told him I had waited he wanted to know why. I told him my decision was based on the blip I had a few months ago and that if my VL came back elevated (as it did, I didn't want to add a new drug to failing regimen without having a picture of genotypic resistance. He was not happy. I know I already have the 215 (AZT) and 184 (3TC) so I wanted to see if further mutations had developed that might cause failure even when adding Viread. I also was afraid that the Viread might knock down the VL below what was needed to get good geno-type and with that in mind I'll fill the Viread after I give the sample tomorrow. I'll let you know what my geno-type report shows and I'll write you back for you advice. I'm thinking at this point of keeping my nukes and adding Viread and Viramune or going to Viread, Kaletra and Viramnue or going with two boosted PIs and either Viread or Viramnue. I read in a recent study that Virmune is as potent long term as Sustiva. Is that accurate from what you know? Also, I'm trying to plot out another regimen for when the next one fails and consider viral fitness (RC) at the same time. We have one researcher here in Atlanta that has long-term patients who have been on everything out there but now stay on Combivir and Viramnue even though they are resistant. The results are pretty fascinating in that because these patients have 215 (AZT), 184 (3TC) and 181 (Viramune), they continue to have replication from the 5000 mark up to the 30,000 mark yet their CD-4 counts remain stable despite the replicaton. Your thoughts? I'll go back to your response from January to get what I can from that. I just don't want to use up all my options in the upcoming regimen. I'm trying to stay one step ahead of the virus. I guess you know the game.

Response from Dr. Cohen

I sure do blipster...

So I'm still awaiting to hear about that genotype you did. But a few points we can make here -

There are different styles no doubt. Such as when to add viread to a "failing" regimen. Given your history of the 215 mutation it is less likely that viread will have a lot of potency left - but it sometimes does - and there are some who even went "undetectable" just by adding this one medication to a regimen that was "blipping" to a thousand. But certainly it is helpful - I agree - to have that resistance test done and cooking before adding something since as you mentioned if it works to get your viral load just low enough to not be able to do another resistance assay but not all the way down - it can be somewhat frustrating in not knowing what the next move can be...

You've mentioned a few moves you were considering - such as the use of a non-nuke with a boosted PI - and there are other options such as this that can become clearer once we understand what resistance pattern your virus has - which is of course based on your treatment history PLUS the test - since the test can miss some resistance patterns that we might have to assume based on just your history...

As for using resistance as a way to slow HIV down - this is an approach some are working with. Sometimes we have to do this - if we cannot identify a fully suppressive combination in those with significant and broad treatment resistance. And it is clear that if HIV is even partially controlled - like 5 thousand - and if it stays there - you might do fine for years. However - the problem is ensuring it stays there. While I've heard whispers about similar combinations to the one you've mentioned - we lack much evidence that I've seen that there are reliable "dead-end" resistance pathways that will keep HIV in check over time. So the fear is 5 thou today, 29 thou next year, and up it sometimes goes from there... as the best way we know to prevent using up options is to reestablish full control. If HIV can grow while on meds - it too often just creates more mutations over time to the meds you are on. Which has led to some novel strategies like using only one or two classes of meds - and for example stopping one class of meds to prevent more resistance happening to this unused class... and other novel thoughts.

So hopefully there's more news on the story you can bring us up to date on?

Confused on treatment

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