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Go for undetectable at any cost?
Jun 22, 2007

I've been positive for 22 years. Until two years ago, I was bothered only by minor symptoms, even though my CD4 count was below 200 for most of those 22 years. Two years ago, intense diarrhea struck and I was hospitalized with wasting syndrome, requiring intravenous nutrition for one year. My viral load was around 90,000 and t-cells remained below 50. Tests showed I had resistance to ALL approved HIV meds. What finally stopped the diarrhea and weight-loss was going on the new drugs MK-0518 and TMC-125. Here is my concern: Although my VL dropped to around 150 just two weeks after I started the new drugs (Hooray!!), should I still be trying to get it to below 50? My VL has been tested three times over the past 9 weeks I've been on this regimen. 170, 110, 143 were the exact results. Of course, I'm happy about this, but because I'm not "undetectable", how aggressive should my doctor be about trying new and different drugs? Shouldn't that be weighed against not using up any future potential drugs? For example, should I go for Maraviroc now (or add Atazanavir, etc.) and try to knock the VL down to below 50? Or should I be content that the number is below, say, 400, and keep some new developing drugs IN RESERVE in case my virus breaks through and I need them? Can us salvage patients use up our potential arsenal too quickly? Should I be satisfied with my "below 200" results and not risk eventually becoming resistant to these brand new classes of drugs? Or am I at risk now anyway because I'm not at totally undetectable levels? Thanks for helping.

Response from Dr. Daar

Thank you for this excellent question.

There are few things that get expert providers yelling at each other more than the question you ask. The reason for the lack of agreement is for just the reasons you outline, balancing the goal of getting to undetectable versus using up options that might be important for the future.

Acknowledging that there are people I respect who might disagree with me, I will share with you my philosophy on this situation. I personally believe that it is very important to achieve undetectable levels if at all possible. If this is not possible with available agents then it is critical that the current drugs be used very carefully to make sure that options are not wasted now when they might be used to achieve the goal of undetectability in the future.

Obviously I do not have all the information needed about you to make any definitive recommendations. In addition, it sounds like you are doing very well on the current regimen and that is extremely important. Because of these facts I would certainly defer to your primary provider as to what should be done next. Nevertheless, from what you have told me it sounds like your viral load is very low but not <50. based upon this I would favor using an additional drug now, if possible to get you to undetectable than save it for the future. The reason for this is that if we get your viral load down now, and you tolerate the regimen well, it is possible that you could keep it suppressed and prevent the development of resistance for many years if not decades. Alternatively, in your current situation you will eventually develop drug resistance to integrase inhibitors and TMC 125. You may then find yourself in a position of not having enough active drugs left to completely suppress your viral load. I worry that if you do not act now you may miss out on the opportuntiy to get the virus suppressed and achieving the goal of preventing the development of resistance in the future.

I hope this helps.

Best, Eric


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