Resistant to one of my meds VL popped to 40

[AusShep]

I'm going to leave the convoluted details as to how this happened out, since they're not relevant at this point I'm equally upset with myself and my Dr.

But, the bottom line is I'm on a Truvada/PI regimen, and when digging through my records after finding out that my VL jumped to 40, I found an old resistance test where I have the A71V mutation, which impacts all of the PIs except Prezista.

I was already wanting to get off of PIs, and was considering a switch to Truvada/Tivicay.  I don't have any mutations associated with Tivicay or II class resistance according to the Tivicay prescriber info.

So my question is if this low level replication that's been going on for a few years could have led to Truvada resistance mutations and I'd be better switching to stribild or something totally new, since I don't plan on having a VL high enough to do resistance testing on ever again...

Going to the dr later today, but got access to my results early through the labcorp website.

[eric48]

40 ...
That is a little low to start thinkîg resistance
Don't you think?

Hope this helps
Mobile.eric

[Ann]

A VL of only 40 is more likely than not just a blip.

So my question is if this low level replication that's been going on for a few years could have led to Truvada resistance mutations and I'd be better switching to stribild or something totally new, since I don't plan on having a VL high enough to do resistance testing on ever again...

Stribild contains the two meds that are in Truvada.

clicky linky

[AusShep]

40 ...
That is a little low to start thinkîg resistance
Don't you think?

Hope this helps
Mobile.eric

No, I had a resistance test done that I didn't know about, that I found in my old records, wasn't by my main doc.  So when my doc has run a test just to see if they could get anything my VL was too low, and I didn't know the hospital had run one on a non related issue several years ago when I was off meds for fucked up reasons.  Found it cruising through labcorp which picked up all sorts of old records.

Yeah, Ann, brain fart, I just meant a non PI, non or Truvada based regimen.  No resistance was shown to NRTI's.  Was just worried if Truvada components could have an issue now. I'm sure it's just a blip, but want to switch anyway and don't want to encourage more mutants than I already have

It is only one PI mutation, and the tests still show the virus is sensitive to the meds, same as those with no mutations.

For the mad scientists like Eric the full list is:

RT: Q102K, K103R, I135P, C162S, K173E, Q174Q/K, R211S, A272P, R277K, R284K, T286A, E297A, V317A, S322T, Q334N, M357T, K358R, K390R, K395R, E399D,
A400T

PR: K14R, L19E, L63C, I64I/V, A71V, V77I, I93L

[Miss Philicia]

I would not even call 40 a blip, I would just call it "clinically insignificant" and not worth thinking about.

[leatherman]

my VL jumped to 40,

40 is not resistant to anything. remember, you aren't cured. You probably got measured when the reservoirs dumped out some virus. Your current meds will (have already) PrEP and PEP those pesky few viruses to death in no time

when you get a VL that jumps up into the 2000-3000 zone and stays that way on the next test, then that's the time to worry about med failure.

[AusShep]

Yeah, I'm just being dramatic I guess.  I was just pissed that there was a resistance test my doc and I didn't know about.  Would've been nice if the surgeon actually forwarded the results which likely came in after I was out of his care.

[Ann]

Shep, which PI are you on? Obviously one of them will be Norvir, but what's the other?

[AusShep]

Shep, which PI are you on? Obviously one of them will be Norvir, but what's the other?

Lopinavir, old school Kaletra, never had the bad side effects others suffered through.  100% compliance the last 5 years except maybe twice took it 12 hours late, just took the whole dose at that time.  Lipids slightly an issue even with Lipitor, but no reason to stick with this ancient regimen.  Stuck with it longer than I should have.

[Ann]

Well, you know what they say; a change is as good as a rest.

I really wouldn't stress about that 40 VL though, particularly if you've normally been UD on this combo. But, if you think it may be some leverage to use with your doctor to get a med change, use it. Why not? Some doctors don't seem to take kindly to a patient wanting a change. Keep us posted.

[AusShep]

He had no issue with changing and said there wasn't any resistance issue since I've been UD with just a blip under 100 every 12-18 months.

I'll be starting Tivicay / Truvada tomorrow.  Guess I'll drop off 2 unopened bottles of Kaletra I've slowly horded up by refilling a few days early off at the local ASO.  Maybe some ass will come in needing PEP that they'd like to try and give explosive diarrhea to for 30 days.

[newt]

40 is not a blip, it's less than 50, which is the benchmark (still) - matt

[eric48]

He had no issue with changing and said there wasn't any resistance issue since I've been UD with just a blip under 100 every 12-18 months.

Are you saying that :
1 - you are concerned with the VL 40
OR
2- you found out this old resistance test and think it was overlooked and that makes you upset

I am not sure your OP was clear about that

Of course the VL is not a matter of concern

As for the overlooked resistance sheet, then... What is done is done... I always insist to have my lab results but in Hospital this can be a pain. I used to loose a lot of time with this... Sometimes my Doc does not have the test results for the appointment! Then I have to reschedule, etc.
We have a commercial lab in front of Hospital. One day, I found out that Commercial lab offers CD4+ VL at ca. $100. On same day as Hospital Blood draw, I walk into the (commercial) lab, get blood drawn (time ca. 30min) , I walk out and get PDF on Internet same day.
Resistance test, though, are expensive... ca. $1000
I keep one sheet but do not have the other (but doc said it came out same)

Because Integrase Inhibitors are very new, the are likely very few resistant strain circulating, and since yours is an old strain , that has co-evolved with you (and your meds), then it is not likely to have I.I. resistance

Does your strains, as described in your old resistance test shows a resistance to one of the components of Truvada (tm) (i.e. TDF+FTC) ? Is that part of your questions ? did Doc answered this ?

Do you have a sorting table ? I mean a table that tells you which mutation affects efficiency of which molecule or just the mutation list

I can look this up for you, using MY sorting table, which should not be obsolete since it is only 4 years old
If this will help you

Sorry I did not get your concerns when reading the OP

All the best w/ T&T

Eric

 

[eric48]

So some minor against LPV/r (Kaletra (tm)) and at least one major ruling out NVP (Viramune (tm)) and EFV (Sustiva (tm)) and none against TDF (Tenofovir (tm)) or FTC (Emtriva (tm)) , the 2 components of Truvada

If I am correct... no so much my turf... I'll let others comment

Eric

[AusShep]

Are you saying that :
1 - you are concerned with the VL 40
OR
2- you found out this old resistance test and think it was overlooked and that makes you upset

I was mostly pissed about #2, would have never started back on the same regimen if I knew.  It was my fault as much or more than my doc, but I was busy moving across country, switching docs, new job, starting back, etc...

My initial concern was regarding compliance studies where some researchers surmised that even with "good" compliance and an UD VL they thought that some resistant replication was likely taking place which could be an impact in the future. 

But anyway, switching meds now, and should have let myself cool down before posting after finding the results late the night before...

[leatherman]

some researchers surmised that even with "good" compliance and an UD VL they thought that some resistant replication was likely taking place

that makes sense. I would imagine that the reservoirs of HIV are still putting out a very limited amount of the initial resistant virus. It's probably because it's a limited amount that even the "wrong" regimen does fairly well keeping the vl in check

said there wasn't any resistance issue since I've been UD with just a blip under 100 every 12-18 months.

so even though this old report showed some resistance issues, clearly the issues aren't doing you much harm if you've been this undetectable for so long. and that's a good thing.

one thing that I would point out is perhaps doing some more research about the exact mutation. Some resistance/mutations actually create unviable virus. These mutations create damaged virus which when they reproduce produce more damaged virus. Eventually this mutated virus is unable to replicate and the virus dies off. I used to have a resistance to epivir; 5 yrs later the mutation was gone. Maybe your resistance/mutation was one of those unsustainable kind.

but since there's nothing wrong with updating to a newer more efficient regimen, hope you enjoy the new meds.

[AusShep]

Thanks Leatherman

I've always been happy for, but secretly a little jealous, of guys like you who can say they've been UD for 8 years.  Maybe this new combo will do the trick.  Interesting about your epivir mutation dying off.

I'm admittedly more sensitive to the dangers of complex resistance than I should be after watching the last of my "drug holiday" friends from the 90's die of KS 2 years ago after running out of treatment options.  Sorry to be a bummer...

[eric48]

Avionate, navigate, communicate, learn

Avionate : remaining UD (even with occassopnal blips) is what you want : good job

navigate : that meds change seems appropriate: hope you will like it

communicate : this resitance test miss show how important keeping/sharing information is important

learn : May  ask one question where you on Kaletra once daily or twice daily ?

Altogether I hope the new combo will suit you. I also hope to help you set aside those fears about resistance.

Hope this helps

Eric

[eric48]

take a walk on the wild side...

http://www.pbs.org/wgbh/evolution/library/10/4/l_104_10.html

(Research environment only..., but interesting approach, and some successfull cases )

(also, All but one Non-class wide Epivir resistances are minors)

Eric

[Miss Philicia]

Avionate

Uh, is that actually a word?

[Jeff G]

take a walk on the wild side...

http://www.pbs.org/wgbh/evolution/library/10/4/l_104_10.html

(Research environment only..., but interesting approach, and some successfull cases )

(also, All but one Non-class wide Epivir resistances are minors)

Eric

This is the last paragraph in the link you provided . If you want to discuss these things do it in the research forum .

The strategy "remains unproved and potentially dangerous,'' warned experts in a journal of experimental AIDS treatments. Until larger studies are completed, the value of structured treatment interruption won't be known. In any case, the discovery has revealed another dramatic instance of evolution in action.

[eric48]

http://www.av8n.com/how/htm/emerge.html

aviate, ( not avionate ) is the proper word. designates the upmost priority for a pilot (manager)

Sorry, spell check not work well on iPhone

Mobile.eric-onate

[eric48]

take a walk on the wild side...

I liked the video because the illustration of how the Wild type takes over is graphic

It provides a rationale/vizualization for Mike's comment. I have No further interest in this matter

Hope this helps

Eric