My daughter has been HIV positive for 12 years. During this time she has not done well at taking meds properly and their is very little left to try. He doctor is hesitant to start anything because of her history and her current drug addiction to Vicodan. Her cd4 count is below 30 and her viral load is very high. With these numbers and her unwillingness to take and stick to meds, what are the risks for her and what oportunistic infections are a possibility.

A person with a CD4 cell count of 30 cells/ml has a high risk of an AIDS-defining opportunistic infection, e.g. 85% risk in three years.

Any of these infections could occur. The most common is pneumocystic pneumonia (PCP), which can be prevented by taking a single pill (Bactrim or TMP-SMX) once daily. She has likely been prescribed this medication, though as you suggest she may not be taking it regularly. Even once every other day TMP-SMX is effective at preventing PCP.

The past 2 years have seen some breakthroughs in the management of people who, like your daughter, have been on many regimens and who have resistance to many or all of the currently availbe HIV drugs.

One new PI - tipranavir - has activity against viruses that are resistant to all other protease inhibitors (PIs). It was just approved by the FDA.

Another new drug - enfurvitide or T-20 - is the first in a new class of ART that targets virus entry into the cell. It requires subcutaneous injection twice daily, which can limit an individual's willingness to try it or to stay with it.

In clinical trials of patients with viruses with multiple resistance mutations, as many as one half of patients who received both tipranavir and T-20 had complete viral suppression and rising CD4 cells for one year.

So the answer to the medical options that might be available for your daugther is that there are such options.

I have no answer for you for the more difficult question, i.e. would she be willing to try them. As you can guess, such a trial would require the same kind of vigilance and commitment that any ART requires.

Even if she declines to consider these newer treatments, there are still treatments that can reduce her risk of serious OIs and mortality. As above, TMP-SMX once daily will prevent PCP, and once weekly azithromycin (1200mg) will prevent another serious OI, i.e. MAC (an atypical mycobacterium).

And there is clear evidence that some ART, even in the presence of drug resistance, is better than no ART.

I urge you to talk to her with her physician, and to consider these suggestions with her and her doctor. There may well be other important considerations in her case that I am unaware of, so her doctor's opinion is essential in these considerations.

Finally, I appreciate the difficulty of your situation. You can't live this reality for your daughter, you can only do your best to help with information and support. Make sure that you take care of yourself and your own needs while you struggle with this.