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?change regimen
Apr 8, 2001

dear dr, I started on nevirapine, lamivudine and stavudine when VL was 33000 by RT-PCR and cd4 was 243. after 20 weeks, VL is 29000. MY drug adherence has been >98. should i go for a change in the regimen to PI's. thanks in advance.

Response from Dr. Cohen

Well - something doesn't make sense here, and before a switch, I would want to figure out why this didn't work. Since a triple combo like the one you took almost always does.

So why did it not work? It is certainly potent enough given your initial viral load and CD4 count, and your adherence sounds ample to do the job. What else can be missing?

Well, assuming the viral load of 29 thousand is real and not a lab error (and lab errors are rare but do happen - so I would first just recheck that test - send it again perhaps...) then there are only a few other possibilities as to how this happened.

First - was your HIV sensitive to these three meds? You don't mention if this was your first combo or not. If yes -then perhaps you are one of those who have a strain of HIV that has resistance to one or more of our commonly used meds. In surveys done in the past few years - we have learned that at least 5% - and as high as 25% - of those who have never taken a pill can have acquired a strain of HIV that has resistance to some of our commonly used medications. And - for example - if your strain even just had resistance to the 3TC/lamivudine - then the combo would work only for a short time - and you might see results somewhat like you describe. Or perhaps this was not your first combo - since 3TC is often used in other first combinations - and also one of the meds that HIV can create resistance to if the combo is not fully suppressive. In which case this combo would have the same problem.

So - is it time to use the PIs? Well - with a CD4 count in the 200's - it is certainly time to define a combo that will work well for you. Whether now or in the near future, you certainly will need to do something soon enough. And given this viral load on nevirapine - you cannot rely on any of the nonnucleosides we now have - since if there is resistance to one - there is resistance to them all. Perhaps it is time now to get some test of resistance to see what your HIV strain looks like - as this may help increase the odds of what you do next. Since it is hard to know how much potency you have left in any of the nucleosides either - from your unchanged viral load - it sounds like there may not be much there either. My guess is that you might need a combo based on a two PI strategy - as we have studies in the past few years showing these can work even on their own. And other studies are now being done - both by our group here in Boston and elsewhere - to update our knowledge with newer dual PI based combinations for those with a similar challenge.

Good luck.



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