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Author Topic: Can anyone clarify whether resistance is inevitable? Confused by mixed messages  (Read 4717 times)

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Offline Delby

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Hi All,

I was just reading Moffie's thread (http://forums.poz.com/index.php?topic=23535.0) and noticed that there seems to be such a vast array of opinions re whether resistance is guaranteed.

Since my diagnosis in Oct 06 (anniversary in a couple of days), the one thing I have never understood is the issue of resistance. I understand the science behind it, but i dont understand when it occurs.

I have been told (pretty much guaranteed) by two leading HIV Dr's, that if i take my Atripla every night (within 2 hrs) then i wont get resistance. However, I have never really believed them as the evidence of how many people are failing their regime's is overwhelming. In the above thread, Dragonette stated she has been taking her meds religiously for 2 yrs every night, without missing a dose, but despite her efforts she has resistance. I am completely confused. What is the truth surrounding this subject?

Is resistance inevitable or can you stay on a regime for more than 10 yrs? I just want to know what to expect so i can manage my expectations a little better. Are my Doctors just trying to allay my fears and feed me a load of unsubstantiated info, or is there truth in what their saying.

It seems alot of people need clarification on this subject so any help from the wise and experienced, i'm sure would be appreciated by all who read this thread.

Thanking those that respond in advance

Confused?!

Delby

Offline dixieman

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On any medication... your body becomes resistant to the effects of the meds... that's why there's not a cure for retro-viruses... the virus continuously adheres and changes... you can keep the virus at bay by taking your meds under the reccommended protocol and by being monitored but, in general the virus will become resistant just as bacteria have found resistance to many antibiotics used today... so the best bet is to stay monitored... compliant with your meds... and hopefully the drug your on will last for a good long time... unfortunately... no... its not going to last forever... 

Offline Peter Staley

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Delby -- I'm sorry Moffie's post confused you.  Let me state this very clearly..  every single AIDS scientist I have talked to over the last few years would say categorically, "HIV resistance is NOT inevitable."

Of course, it happens, and it happens with various frequency, depending on a person's circumstances (prior treatment history, being infected with resistant virus, etc.), but all the experts agree, there's plenty of evidence to show it's not inevitable.

Offline Moffie65

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I am truly sorry for the confusion.

Dixie is mostly right in my view, but the evidence shows us that SOME people can and do achieve a very effective treatment plateau, which lasts for years.  Aztecan is one here who has been on his meds for years, and has yet come to resistance.  I and many others on the other hand, have been faced with Resistance time and time again.  

From what I now know, drug Resistance comes not only with the virus you receive from who ever infected you, but also the nature of your own immune system prior to infection.  In other words, most viruses fall under a few categories, and their ability to build resistance varies.  Also, everyones' immune response is different, so there is no way a Doctor can truly assure you under any circumstances that your virus will NOT become resistant, but truly the vast numbers of people living very healthy lives, therefore proves he might be very correct.  Nobody ever knows without really going through it.  Assurances about the future of your health are still probably not really a good thing to do, but hopefully in five to ten years, Doctors will be more correct than not if they project a solid nonresistant outcome.

There are researchers on this forum who will have a far more informative answer, but this is mine.  There was no intention of alarming you, only  words of caution to help you stay on top of this disease.  It is never a static disease in most cases, but in many it really is.
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Online Miss Philicia

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This question still irks me, mostly because there's some lousy semantics involved.  This "inevitable" word implies certainty, and seeing how there's not a single HIV patient to point to that's been on the same regimen for 50 years in existence it's (somewhat) irresponsible to use it IMO.  Why?  Because the bottom line here, and you can see it AMPLY illustrated in Delby's OP is that the underlying issue is a mental one of managing expectations.  Managing expectations is quite simply integral to managing one's disease.  When one implies this level of certainty it will only freak out a patient when they (possibly) encounter resistance five years down the road.

There needs to be a better way of stating this "inevitable" thingie.   I think Moffie's basic point (correct me if I'm wrong honey) is that this certitude on the part of doctors and scientists does a disservice to many people -- like the converse of saying HIV is a "terminal disease."  And you can read between the lines of Delby's post and he senses that he's being fed some BS so that he can tenderly sweep his concerns under the rug.

Personally I consider the question basically unanswerable with any degree of certainty, but that's just me.  There are simply too many cavaets, and one of those examples in mental management of a disease where perhaps you shouldn't worry about it until it happens.
"Iíve slept with enough men to know that Iím not gay"

Offline veritas

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I don't know  if this sight will answer your question directly, but it helped me to better understand resistance:

http://www.hivresistanceweb.com/protected/po.shtml

It also has a Q&A.

Offline Assurbanipal

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I don't know  if this sight will answer your question directly, but it helped me to better understand resistance:

http://www.hivresistanceweb.com/protected/po.shtml

It also has a Q&A.
Interesting but the site does not appear to have been updated since 2003 (the "new" papers are from 2002 etc.)
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline veritas

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Assurbanipal,


Thanks for pointing that out. Ihad it saved in a file and didn't review it(my bad). Here's another one that is perhaps more relevent to Delby's question:

http://biocreations.com/animations/english_HIV/main.swf



Offline newt

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Resistance is generally unlikely if starting treatment these days and sensitive to all drugs to start. It is NOT inevitable, or even likely.

Provided..you take your meds on time.

- matt
"The object is to be a well patient, not a good patient"

Offline David_CA

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I asked this question in Moffie's thread, but I think it's more relevant here.

I'm curious about replication and mutation.  We all know that the virus is in various parts of the body but not in measurable amounts in the blood.  Are the mutations that occur in these non-blood locations (part of) the cause of resistance?

David
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  Atripla started 12-01-2006
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06-03-10 CD4 768 @34.9%
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Offline Delby

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Firstly thanks to those that replied!

I must say, i'm still very confused. If its not inevitable, then why are people with no previous resistance to starting meds, who religiously take them without missing a dose, becoming resistant from 1st line therapy.

I could be wrong, but i seem to remember reading a statistic that stated nearly 80% of people fail 1st line therapy in time. I dont have the article, but i have read that type of info quite often. I have also heard so many people saying that its 'just a matter of time before the meds stop working'. This is such a confusing issue.

If resistanse wasnt inevitable then why have the majority of people been through a number of therapies on these forums. There seems to be very few, if any that have survived on the same regime for over a decade, due to resistance. Also, I keep hearing the same point, that if a person is starting on the newer class of drugs, such as Atripla, then resistance issues are low. However, from what i understand, and again i could be wrong, is that Atripla is just a combination of old drugs that have been around for over 10 yrs. So how is it any different to 10 yrs ago, or when combo therapy was first introduced.

Again, thanks to those that replied, but if you can shed some more light on the subject it would be very helpful to us all.

Delby  ???

Offline tash08

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Malabsorption is, unfortunately, a not uncommon problem in people living with HIV which can greatly diminish how well a drug is taken up by thebody. When it is present, you won't be receiving the full dose of the drugs you're swallowing.
Even if you're doing everything else right in terms of your scheduling and dosing of drugs, it won't
do you any good if they're not getting through the intestinal wall into the bloodstream. When
drugs are only partially absorbed, the effect will be the same as taking a dose that's too low.
They will work less well, allowing greater viral activity and speedier development of resistance.

http://www.larklands.net/TR9_Increasing-Absorption.PDF

Glutamine is required for the constant
rebuilding of intestinal cells. These cells are regenerated every 3-4 days. The energy which
allows this process to occur comes from glutamine. If glutamine concentrations are low, the result
is intestinal tissue atrophy and decreased absorption of both nutrients and drugs. Maintaining
intestinal health by ensuring the presence of optimal levels of glutamine in the body may be one
of the most important things you can do to lessen the chances for resistance developing. If the
absorptive capacity of the intestines is good, then you will actually be getting the dose of the drug
that was intended, rather than a suboptimal level that could hasten the development of resistance.
Other nutrients necessary for the proper building of intestinal tissue may also be in short supply
so a total approach to building and maintaining healthy intestines should be an integral part of
anyone's antiretroviral drug program.

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05/02/11 CD4-638, VL-UD <20 copies Hell yeah!
08/3/12 CD4-806, VL-UD

Offline Assurbanipal

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I could be wrong, but i seem to remember reading a statistic that stated nearly 80% of people fail 1st line therapy in time. I dont have the article, but i have read that type of info quite often. I have also heard so many people saying that its 'just a matter of time before the meds stop working'. This is such a confusing issue.

There's a lot of old data floating about on the Internet, much of which does not reflect ithe effects of modern HAART. Here's a recent article discussing the significantly greater time people are lasting on their first line therapy
http://www.aidsmeds.com/articles/hiv_treatment_durability_1667_15274.shtml

For more detail on a specific drug, here's a 7 year study of Kaletra (combined with various NRTIs) where about 60% did not develop resistance (at least as measured by virologic failure)
http://www.ncbi.nlm.nih.gov/pubmed/18215977?dopt=Abstract

And here's a study centered around Sustiva, which found that at 3 years 75% had not developed resistance.
http://www.ncbi.nlm.nih.gov/pubmed/16905783?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVBrief

Both of the above are cited in the CDC treatment guidelines
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf

Regards
A

(edit -- caveat on how resistance was measured)
« Last Edit: October 09, 2008, 10:37:09 PM by Assurbanipal »
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline atlq

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Delby,

Bottom Line: If you are adherent to your meds, resistance is unlikely to develop. You should be able to continue on your initial therapy for a very long time. If resistance does develop despite your adherence, well that is just a risk we all share. You then get a resistance test done and move to Plan B (or C or D).  I think that obsessively worrying about unlikely possibilities is one of the worst things you can do, as far as your health is concerned.

Best.... :)
« Last Edit: October 09, 2008, 11:40:21 PM by atlq »
ďKeep up the good work....   And God bless you.Ē
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Online Miss Philicia

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I think that obsessively worrying about unlikely possibilities is one of the worst things you can do, as far as your health is concerned.


qft
"Iíve slept with enough men to know that Iím not gay"

Offline LordBerners

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I asked this question in Moffie's thread, but I think it's more relevant here.

I'm curious about replication and mutation.  We all know that the virus is in various parts of the body but not in measurable amounts in the blood.  Are the mutations that occur in these non-blood locations (part of) the cause of resistance?

That's what always made sense to me, David.  If the medications don't eliminate the virus, then there is still some virus doing its normal thing somewhere in the body, and thus it must have some potential for mutation.  By contrast antibiotics often fully kill off the bacteria they're aimed at.

I'm not claiming I know anything, nor am I disputing any medical authority, and least of all am I attempting to advise or discourage anyone.  I'm just saying I personally have a somewhat less than rosy view about the issue.
Please, just call me Berners.. or Baron.

Offline newt

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Quote
By contrast antibiotics often fully kill off the bacteria they're aimed at

This is not true mostly, antibiotics tend to create an environment where bacteria can;t replicate (ie are bacteriostatic) and let your immune system clean up the mess.  Much like antiretrovirals. Resistance is also an issue with antibiotics...

Compartments, well 90-95% of people will have matching virus populations in blood and elsewhere on treatment if viral load is suppressed under 50 copies/mL. I am trying to find one easy study to post on this topic.

People who have treatment that don;t work regardless of adherence either (1) had undetected resistance to start with -- tests is not perfect (2) as a previous poster said, did not absorb enough of the drugs -- this is an important issue (3) had been on many regimens before, perhaps from the early days.

The rate of treatment failure these days, adherence aside, is much, much less than 5-7 years ago, most common reason for a switch is side effects/possible side effects.

- matt
"The object is to be a well patient, not a good patient"

Offline Ann

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Matt,

Thank you so much for being the voice of reason here. The next time one of the British papers has one of those "heroes of Britain" awards, I think I'll nominate you.  :-*

Ann
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Offline LordBerners

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Compartments, well 90-95% of people will have matching virus populations in blood nd elsewhere on treatment if viral load is suppressed under 50 copies/mL. I am trying to find one easy study to post on this topic.

I'm sorry I don't understand what you are saying here.. What are 'compartments'?  Or 'matching virus populations'? 

Also can I ask you if - when one is at a low ('undetectable') virus level - the virus is  still replicating or just in some kind of stasis?  If the former, how can it not have the potential for developing resistance?  I'd like to stress I am not disputing your or confronting, as I know nothing, but rather just trying to understand.
Please, just call me Berners.. or Baron.

Offline newt

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See:

i-base Manual - 2.11 Compartments and sanctuary sites
http://www.i-base.info/manual/en/2-11.html

Basically, HIV seems to enter the body first into the lymphatic system, then spreads to blood, then to other parts of the body eg spinal cord, brain, gentials.  Each separate part of the body where you can find virus/drugs in different concentrations is termed a compartment.  Viral populations can be different genetically in blood and elsewhere. but mostly they are the same or very similar (ie matching)

On treatment, it seems 90% of people with very low viral load (50 copies/mL or less) as measured in blood will have the same elsewhere, but sometimes it can be higher. Typically, if it is higher is seems to be no more than 1 log higher, ie up to 500 copies/mL. There have been a few reports of much higher levels. The reason for this is unknown.

Resistance can also be different in blood and compartments, but this is uncommon -- and in terms of affecting treatment, since most of the virus is in unactivated CD4 cells this is unlikely to appear elsewhere unless there is some kind of immune activation (eg for the genitals, acquiring an STI).

There is a slow exchange of virus from compartment to blood (sometimes called traffic)

As to why 50 is the magic limit for statis, ie viral replication is insufficiently complete and insufficiently large to count...

...in the presence of treatment, it seems any replication is very localised, not enough virus is produced to activate the immune system and have lots of CD4 cells etc rush in, get infected, and distribute mutant virus round the body: bit like a sparkler compared to a Disney firework display, just too small and local to inspire shock and awe.

Furthermore, by using 3 drugs, even if a virus developed in a CD4 cell with 1 resistance-causing mutation, it is unlikely to develop sufficient mutations to all drugs to allow it to complete its replication cycle and escape unharmed, or do so in sufficient quantity to attack other CD4 cells in volume and become generally established (hence effectiveness of combination therapy).

- matt
"The object is to be a well patient, not a good patient"

Offline joemutt

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Thanks for that Matt.
It s clear language.

Offline 100proofBrandy

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Delby,
I have been on the same meds for 7 years, and as of my last dr appt I am still undectable(48) and my cd4 is 698 @ 31% I believe that just like everything in this world its more a matter of your body not everyone can take the same meds and not everyone reacts to this virus the same,keep taking your meds everynight and keep going to the dr, eat right and keep healthy in body and mind, try not to stress that not good for anyone!!!! 
The person you educate today maybe the one you save tomorrow :)

Offline LordBerners

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Thank you so much newt for your kind explanation - I do feel I understand now.  Particularly your point about the low (though not non-existent) level of replication not being enough to overcome the three-drug 'combination punch'.  I forgot about that.

Interesting about the issue of other infections activating CD4s and thus creating greater potential for virus spread, replication, and finally a potential for resistance developing. 
Please, just call me Berners.. or Baron.

Offline Delby

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Just want to thank everyone that replied, for all your input and time spent on this thread.

I have to admit though, i am still confused as to how long someone, in theory, can last on their initial therapy options. Has it ever been documented that someone has survived on initial therapy for over 10 yrs say. If resistance is not inevitable, then in theory one could survive on their initial therapy for the duration of their life - all else being equal.

I guess what i have learnt from this thread, is the data and evidence is still too premature to make any substainiated statements as to how long initial therapy can last for.

Thanks again to all those that replied!

Delby

Online Miss Philicia

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Just want to thank everyone that replied, for all your input and time spent on this thread.

I have to admit though, i am still confused as to how long someone, in theory, can last on their initial therapy options. Has it ever been documented that someone has survived on initial therapy for over 10 yrs say. If resistance is not inevitable, then in theory one could survive on their initial therapy for the duration of their life - all else being equal.

I guess what i have learnt from this thread, is the data and evidence is still too premature to make any substainiated statements as to how long initial therapy can last for.

Thanks again to all those that replied!

Delby

Look honey, you need to stop dwelling obsessively on this.  HAART has only been in existence for 11 years.  I'm sure there are a handful that are still on their 1997 regimens but keep in mind that the first protease inhibitors are not the ones generally given out at first now, nor will the current ones be the first line choice 5 years from now.  This topic is all informed guess work.

Why don't we talk about why you're fixated on this one topic?  HIV treatment isn't static -- in my experience it's changed every 5 years or so in terms of options.  There are NO GUARANTEES in HIV treatment, so you need to learn to deal with things when they happen and not obsess about stuff or you're going to develop a nasty anxiety disorder.
"Iíve slept with enough men to know that Iím not gay"

Offline Peter Staley

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Delby -- we've got 7 year data for Kaletra:

http://www.natap.org/2005/EACS/eacs_9.htm

"Through 7 years (360 weeks) of follow-up, antiretroviral-naive subjects receiving LPV/r-based therapy exhibited sustained virologic responses, with 61% of subjects demonstrating HIV-1 RNA <400 copies/mL and 59% demonstrating HIV-1 RNA <50 copies/mL by intent-to-treat (NC=F) analysis. Corresponding on-treatment response rates were 98% and 95%, respectively."

What this means is that of those originally enrolled, approximately 60% are still undetectable, although that number is low because a lot of patients left the trial before the 7 year mark (they could leave for any number of reasons, like choosing to switch therapies).

Of those that stayed in the trial all 7 years, and are still on Kaletra, 95% are still undetectable.

Please chill out.

Offline YaKaMein

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Thanks to Matt, Peter & Philly for reinforcing my faith and commitment about current treatments including mine. We can be consumed by possible drug resistance but to what end?  Personally, I've decided to focus definitive action and battle this virus [and life's curveballs] on many fronts, including HARRT. I do this without guarantee that I'll win. The world is full of risk and uncertainty.
09/11 Endocrine Consult
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 Disc'd Bactrim DEXA -3.1 Tscore
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07/10 CD4 336 14.0% VL 0 DEXA -2.7 Tscore
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01/10 Began FOTO
11/09 CD4 274 13.7% VL 0 Chol 173 Trig 131
07/09 CD4 324 13.5% VL 0 DEXA -3.1 Tscore lumbar
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11/08 CD4 227 10.3% VL 0 Chol 176 Trig 156
04/08 CD4 228 9.5% VL 0
01/08 CD4 194 9.0% VL 0
09/07 CD4 176 8.3% VL 0
03/07 CD4 130 9.5% VL 0 Chol 261  Trig 227
12/06 CD4 109 6.4% VL 0
09/06 CD4  88 5.5% VL und desens'd rtd to Bactrim
08/06  Began Atripla
07/06 CD4  59 5.0% VL 145 Chol 117 Trig 104
06/06  Bactrim rash, X2 Dapsone
 EFV & Truvada Chol 128 Trig 131
05/06 CD4  6 (2.0%) VL 78667 only V179D mutation Dx PC MAC

Offline blondbeauty

  • Member
  • Posts: 1,784
Always listen to Matt. Once your viral load is undetectable, resistance is very unlikely. If the virus is not replicating it can not mutate to a resistant "version" of itself. Think about a population of cockroaches in your cellar...if the insecticide you use, prevents them from having new babies, you can't have new generations of cockroaches resistant to the insecticide you are using. But if the poison is not potent enough, they will be able to have new babies with mutations that will make then resistant to it and you will have to start using a new product.
Of course...you must stick to treatment faithfully.
« Last Edit: October 14, 2008, 07:00:52 PM by blondbeauty »
The only member in these forums approved by WINBA: World International Nail and Beauty Association.
Epstein Barr +; CMV +; Toxoplasmosis +; HIV-1 +.
Counts when starting treatment:
V.L.:80.200 copies. CD4: 25%=503
Started Sustiva-Truvada 14/August/2006
Last V.L.count (Oct 2013): Undetectable
Last CD4 count (OCT 2013): 52%= 933

Offline StrongGuy

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  • Posts: 492
I can't add much more than to say you've received some great advice from many in this thread - especially Matt and Peter. While it's easier said than done, trying not to let your head race with worry over what is or is not inivitable is an important objective when dealing with HIV.

Keep your chin up - try to stay focused - and wishing you all good thoughts!

:)
"Get your medical advice from Doctors or medical professionals who you trust and know your history."

"Beware of the fortune teller doom and gloomers who seek to bring you down and are only looking for company, purpose and validation - not your best physical/mental interests."

"You know you all are saying that this is incurable. When the real thing you should be saying is it's not curable at the present time' because as we know, the great strides we've made in medicine." - Elizabeth Edwards

Offline Delby

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  • Posts: 117
Again, I just wanted to thank all of those that replied - again! Your support, imformation, knowledge, is invaluable to us all. Thank you all for being patient.

Having read your replies, i feel much more positive about this subject and have decided to take your advise and try not to obsess about endless 'what ifs'.

Thanks again to all of you!  :)

Offline veritas

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  • Posts: 1,410

Delby,

The attached is the latest research I could find, I hope this helps to further explain resistance:


http://www.thebody.com/content/confs/aids2008/art48190.html

Offline leatherman

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  • Posts: 6,225
  • Google and HIV meds are Your Friends
http://www.thebody.com/content/confs/aids2008/art48190.html

thanks for that link.  ;) there is a great explanation buried in the middle of that transcript that explains the blips that occassionally happen to the viral load.

Quote
In fact, blips are likely just a reflection of the fact that everybody on HAART is viremic due to the release of virus from stable reservoirs, and that there will inevitably be some biological and statistical fluctuation in the level of residual viremia that is occasionally captured as a blip.

it's kinda nice to know that each of those blips is another batch of "hidden" HIV that has been released to be tackled by the meds I'm taking.
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline mewithu

  • Member
  • Posts: 160
  • mewithu
Follow atripla especially by as close to the hour as you can,it is the worse one for getting resistant to if you get too far off schedule.
1997 is when I found out, being deathly ill. I had to go to the hospital due to extreme headache and fever. I fell coma like,  two months later weighing 95 pounds and in extreme pain and awoke to knowledge of Pancreatis, Cryptococcal Meningitis, Thrush,Severe Diarea,  Wasting, PCP pneumonia. No eating, only through tpn. Very sick, I was lucky I had good insurance with the company I worked for. I was in the hospital for three months that time. 
(2010 Now doing OK cd4=210  VL= < 75)
I have become resistant to many nukes and non nukes, Now on Reyataz, , Combivir. Working well for me not too many side effects.  I have the wasting syndrome, Fatigue  . Hard to deal with but believe it or not I have been through worse. Three Pulmonary Embolism's in my life. 2012 520 t's <20 V load

 


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