Hi Doctor, I am a 50 year old female, 5' 6" and 128 pounds. I tested positive in 1985, began monotherapy with AZT in 1994, became disabled and started a PI combo with norvir in 1996. While PI combos have effectively treated my virus (although I've never been undetectable), I have never been able to tolerate tolerate the PI side effects, which make me as sick or sicker than AIDS. In 2003 I switched to a non-PI combo of Ziagen, 3TC, DDI, and eventually Viread. While not great, my health and VL/TCells held pretty steady in the 10,000/180 range and then slowly deteriorated. By May 2006 my VL had gone up to 200,000 and my TCells down to 115 and I felt poorly enough to try a PI combo again. My doctor and I put me on Kaletra, Truvada, and Sustiva (I had held back the Sustiva for years wanting to save it for when the old drugs would stop working.) I tried my best to stay on this combo, knowing my choices were limited, but after 6 months (and good lab response--VL 110 and Tcells 285 in Nov), I had lost 20 pounds and my fatigue got progressively worse to the point of almost constant exhustion. After the 5th month we switched the Kaletra to Reyataz hoping the side effects would improve, but they didn't, they continued to get worse. I recently have stopped everything for a week or two (with my doc's okay, and stopping the sustiva first due to the long half life) and I'm worried about what meds I will go on next. Would it do any harm to try a non-PI combo of Ziagen, Truvada, and Sustiva? Or do you have any other options (I do not want to take T-20 unless its my only choice)? thanks for any insight, I appreciate this service termendously.

Thank you for your post.

Your situation is like many where therapeutic options are limited by both drug resistance and tolerability. Making treatment decisions in a situation like this requires a great deal of thought and as much information as possible. This includes all of the details regarding previous therapy, viral load while on each regimen as well as how well the various medications were tolerated. Any drug resistance data is also very helpful. I realize that it is virtually impossible to provide this much detail in a posting like this but it is important for me to provide you these caveats and encourage you to go through all of these issues with an expert provider. In the absence of the more detailed information I will provide some general information that I hope will be of some value.

In a case like yours the first thing I would do when all information is available is define which drugs you have clearly had side effects to that make them an unreasonable option for future regimens. I would then go through your treatment history and any drug resistance reports and determine which drugs are likely to provide little benefit as part of a future regimen. While this strategy seems simple it is often quite complex and again relies upon a very experienced provider. In particular, it is often difficult to determine which drug within a complicated regimen is actually causing or caused the side effects you experienced. It is similarly not always straightforward determining which drugs you have developed resistance to and requires careful assessment of resistance test results and treatment history.

If after this exercise with your provider it is determined that there are insufficient drugs that you are either susceptible to and/or can tolerate then it is important to be very strategic at this point when your CD4 cells are reasonable, particularly if you are without symptoms when not experiencing drug related toxicity. The future is very bright for you with the anticipated availability of integrase inhibitors and possibly CCR5 inhibitors in the next year. If you can not achieve undetectable levels of virus now without substantially impairing your quality of life then you should be on select drugs that you tolerate and maintain your CD4 cells until these new drugs become available to you in the near future.

I regret that I could not provide you specific information about your case with the information available but I hope the strategy outlined above along with the support and expertise of your provider will lead you to a long and healthy future.

Best, Eric