Resistant to All But PIs, Integrase and Maraviroc; Can Only Take Cobi For Booster

Question

Dear Dr. Henry,

My virus is resistant to all families of anti-retrovirals with the exception of protease inhibitors, integrase inhibitors, and Selzentry (maraviroc).

I have been off treatment for 3 years awaiting FDA approval of Tybost (cobicistat), because I cannot tolerate Norvir (ritonavir); it caused my ALT/AST levels to go off the charts. My CD4 is ~325 and viral load is 18K; both have slowly worsened over the years without treatment, but never a spike, nor have I felt appreciably sick, yet. Nevertheless, both my doctor and I feel the time is right to start treatment, now that Tybost has finally been approved to provide me with a booster I should be able to tolerate.

Due to my resistances, my doctor has proposed one of three treatment options: 1) Prezista (darunavir), Tybost and Tivivcay (dolutegravir); 2) the three just listed, combined with a trial low-dosage of Maraviroc (150 mg) to see if I can tolerate Maraviroc since it is supposedly contraindicated by Tybost (per Hippocrates drug interactions app); or, 3) check for a second opinion to see if theres something out there we havent considered, or perhaps a way for us balance out the proposed drugs contraindication.

As someone with a highly-resistant virus, I want my treatment to be as broad-based as possible to lower the chances of mutation, and I feel rather unsure about the prospects of attempting to control the virus with boosted-Prezista and Tivicay alone (i.e., just using a PI and an integrase inhibitor). I am only 27 years old, I want to control this virus over the long-term and want to maximize my treatment to prevent relapse and development of further resistancethe two options on the table both seem like a gamble.

Can you please provide me with an assessment of what my doctor has proposed thus far, what you think the safest approach might be, and let me know whether there might also be alternative medications/treatment/dosing options we might also want to consider? I greatly appreciate your time and advice.

Best regards.

Answer

You dont mention whether virus is resistant to etravirine which may give you another option/drug to consider. It also remains unclear whether also utilizing NRTIs such as tenofovir/FTC (Truvada) would add much in the setting of resistance but many experts still consider adding that drug even if resistance present. Another drug that can be used is Fuzeon (at least until HIV level undetectable on a new regimen). That being said it seems very likely that a cobi + darunavir + raltegravir or dolutegravir + Truvada yes I would still use that drug in many cases such as yours) would suppress your virus (2 highly active drugs in being used with relatively modest viral level). Let us know what happens-good luck. KH