Hi Eric,

I find myself once again at a point where my current combination of Epivir,Viread and t-20 has become ineffective. My latest bloodwork is 100 cd-4 cells and a viral load of 750,000 (from 150 t-cells and a viral load of 55,000). I am very treatment experienced with high resistance to all current drugs. I have been looking for information about mega haart combinations since that is what my Doc and I have talked about as my next option so I can wait for more than one effective agent. I assume that a lot of the decision regarding mega haart depends on my pheno type test, but since I am highly resistant to everything, where do I begin in selecting a "bridge" therapy from my old meds? Thank you in advance for your time and energy!

Jeffrey

Hi Jeffrey, Thank you for the post. I am sorry to hear that your virus is so drug resistant. I do hope that you have remained clinically well through all of this. I can't emphasize enough that you need to continue to discuss your situation with your expert provider who has access to much more information about you than I. However, I can make general comments to you which would also apply to many others in your situation.

First of all, Megahaart is a term used in the past that we seldom use anymore. It was meant to describe using 6 to 9 drugs together. Often it was implied to mean that none of these drugs were active but the hope was that using them together in large numbers would help anyway. Data with this strategy from some years ago was mixed with regards to viral control, but often associated with significant toxicity. In the current era I think of our use of treatment to be more strategic, and if it does include many drugs it is for a good reason.

In any event, you are correct that in your situation drug resistance testing will be key in determining how to proceed. If review of your treatment history and resistance testing showed that you had two or more fully active drugs to use I suspect you would have already done so. Based upon what you write I would guess that testing shows either one or no fully active drugs. In this case you do want to remain on a stable regimen while you await future treatment options. The good news is that you will almost certainly respond to integrase inhibitors, one of which is in expanded access, and you have a chance of responding to a new NNRTI, etravirine, also just recently in expanded access, and possibly the CCR5 inibitor maraviroc which we hope will reach expanded access in the coming months. Just to be clear, expanded access means the drug is not yet approved but being made available to select people who need new options. Usually these drugs are approved during the next months.

At this point most experts would agree that you should remain on a combination of two or three NRTIs that include either 3TC or FTC. Whether this is with tenofovir (viread), zidovudine (ZDV) or both plus or minus others is really not known and may in part be determined by resistance testing data. Whether you should remain on a PI is an open question and one I would encourage you to discuss with your provider who has additional information regarding your PI resistance pattern. I would strongly discourage the use of a NNRTI in your next regimen until you have the opportunity to include etravirine with other potentially active drugs, such as integrase. Finally, the utility of continuing T-20 at this time is not known. Nevertheless, the limited data available suggests that it is unlikely to contribute much to maintaining viral load and CD4 cells after you have been on it for several months with ongoing viremia. That said, if you find that your T-cells decline after discontinuing T-20 you may want to consider adding it back.

I hope this is of some help. I am sure your provider will provide even more helpful information. Remember, new options are literally right around the corner.

Best, Eric