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Doing Well, But Final Combo
Aug 6, 2001

Dear Dr. Cohen: I know that this is a difficult question to answer factually - but I'd really appreciate your opinion. I've been on too many drug combo's to count - none of them worked until now. I'm taking Kaletra, Viramune, Ziagen, and Epivir - My CD4 count has gone from 6 to 83 and my VL has gone from 90,000 to undetectable (the first time ever). Anyway, this was really the last combo left for me to try and luckily it's working. I've been on it for about 6 months now. My question is, how long can I HOPE for this to work and then what? Any idea's on life expectancy?

Response from Dr. Cohen

Can't tell you much specifics but can make a few general points.

First - it is unclear what you mean by the term undetectable - since there are different tests out there that define this. In general, however, when a regimen is potent enough to get the viral load to below 50 copies for at least a few months, it appears that these regimens have the potential to last for a very long time. The reason is that with this degree of suppression, new resistance mutations are pretty unlikely. Not impossible unfortunately - but even if new mutations do arise, it still takes a long time. So that may be one way to judge how long this regimen will work for you - if your viral load is <50 and has been for say, three months, then you might even expect years from this combo. Assuming you take it each day each dose - since erratic adherence sadly is the single most controllable issue we know of that determines ongoing versus quite limited duration of successful suppression. There are other factors that can and do arise - some don't absorb these meds well enough to do the job for example. But it appears that these issues are not the usual problems we face in maintaining control.

Now, if your viral load is <400, and that is the best test of viral load you have access to, it may be <50. But it may be in the inbetween range. And it appears that if the viral load is in this range of 50-400 many studies suggest that in time, the viral load may head back up. If that is the case, one thing you might consider is "intensifying" this regimen with other antivirals. For example, adding one more drug. At this low level of viral growth we can't do a resistance test, so we would either rely of prior resistance testing, or just best guesses. The usual options here might include a drug expected to gain approval soon called tenofovir (Brand Name is Viread pronounced vi-ree-ad, NOT Vi-reed!). Or another nucleoside that you have used in the past that might still have some activity left - such as ddI/Videx. Or even another protease inhibitor - since the ritonavir contained in the Kaletra can "boost" the blood levels of most of the other PIs allowing them to be more active than usual.

As for life expectancy it is again hard to be specific but one more point. At our most recent meeting Dr Julio Montaner showed us a dramatic graph of the power of treatment. He showed that while those with a CD4 count below 50 cells are at the highest risk for serious illness, those who were on treatment and very adherent to the regimen had a prognosis that was overlapping of those at higher CD4 counts. Since active meds that you take can and do work. And new ones are coming. So it is not crazy to think that your life expectancy, given your current combo, can be counted in decades...

Hope that helps.



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