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HAART failing? What next?
Aug 28, 2000

Hello doctors! I'm a 38 yo male, first diagnosed HIV+ 10/98 (probably infected 01/93). Mostly asymptomatic (except for a few minor, and successfully treated, skin conditions such as molluscum contagiosum). Initial genotype assay suggested possible resistance to some PIs, including indinavir. Started HAART 04/99: abacavir, 3TC, efavirenz. baseline: VL = 49,000 / CD4 = 183 (15%) 05/99 (4 weeks): VL = 765 / CD4 = 252 06/99 (8 weeks): VL = 154 / CD4 = 202 08/99 (15 weeks): VL = 64 / CD4 = 340 12/99 (31 weeks): VL < 25 / CD4 = 385 (23%) 03/00 (46 weeks): VL < 13 / CD4 = 472 (25%) then things got worse 06/00 (58 weeks): VL = 125 / CD4 = 350 (26%) 08/00 (66 weeks): VL = 796 / CD4 = 456 I'm still asymptomatic and any minor health problems I've had are not (according to my physician) OIs. I'm very stressed (also seriously underemployed and suffering from anxiety, which doesn't help). My doctor thinks it's fine and if things get worse I might have to switch to a PI. What's your take? 1. Should I be concerned about the increase in VL? 2. Should I get another genotype assay to see if I'm resistant to any of the current meds? 3. Are there other options besides PIs? Thanks a million!

Response from Dr. Cohen

Hey -- thanks for the organized query. Sorry to hear about that stress level -- that too can be managed, even with medication if that is what you need for a while...

As for these labs -- yes you are doing well. But yes, the rising viral load is a bit surprising and of some concern given the choice of meds and your initial lab values. It however does suggest some initial loss of full effectiveness from these meds. Although sometimes the viral load can head back down after a temporary rise -- so worth rechecking next month. And as you can see -- the CD4 benefit is still there and likely will remain there for quite some time.

But the controversy is when to do something else here -- since a sustained viral load near to 1000 copies -- assuming your next one continues with the current trend -- suggests that this combo is still working but not at full steam. And it may hover at this stalemate for a long time -- perhaps not just months but even for years. And even if you have some resistance to these meds now, allowing them to do what they can for you still doesn't lose any of the future benefits from the PIs since there would not be any cross resistance from these meds to that class for you. But the longer you remain on this, the more resistance you likely would have to some of the other nucleosides -- since there might be some mutations that could arise from abacavir use that have some impact on the other agents.

One option is to do a genotype, or phenotype study. These tests can often measure HIV once the viral load is over 1000 -- and you might be there on your next test. But if your viral load is below that -- these tests are less reliable. Fortunately if your viral load is below 1000 -- there isn't as much urgency to changing anything at that point.

One option you still have now is to add a fourth med -- one from the nucleoside class -- the usual choices would include AZT, d4T, or ddI. These would add additional potency and help drive your viral load back below 50. And if it was successful in doing this, it might allow this otherwise compact and thus attractive combo to last even longer. And while every med has a pro and a con -- there are many who have used any one of these three and done well on them for months to years. There is even some recent info about whether adding a second non-nucleoside to this combo would offer any added potency -- but most of us would doubt it as a strategy here.

It is worth just a moment to reflect on why these meds might not have been fully effective -- since in general they would be. The issues would include whether you had some resistance already to these meds before you started -- since you mention that you saw some resistance to the PIs -- and it may have also been there for these meds but just not picked up on the test. The other reason is optimal medication adherence -- and we know from experience that many just have trouble remembering to take meds every day twice a day. Worth noting so that if this were a factor you might do what you can to improve on that aspect as well...

Hope that clarifies. Let us know what happens.



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