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Many Mutations 7 Quest Posted: Oct 17, 2006 QUESTION: Sorry Another experienced patient 44 years old 10 years ADIS Very experienced. Healthy, asymptomatic except for severe facial lipoatrophy and working full time 6 years ago a colleague put her on d4T EFV LPVr and ABV Three years ago I stopped the EFV. Over the years Genotypes and Phenotypes ahve documented 11/04/1999 M41L, D67N, T215Y, L214F M46I, A71V, M36I, I84V, L90M, V77I, L10F 10/12/2000 M41L T215Y/F L74V Y181C G190A/E/S L10F M36I M46I/L L63P A71V V77I I84V L90M 03/20/2003 M41L L210W T25Y/F K101E Y181C/I M36I M46I I47V I54L L63P I84V L90M 2/15/2006 PHENOTYPE - M41L D67N L74L/I GV118I L210W T215Y K219N K101E Y181C G190A L10F K20I M36I M46I I47V I54V L63P A71V G73S I84V L990M REDUCED SUSCEPTIBILITY TO ALL ON THE PANEL, including TPR However her CD4 counts have remained in the 300's and her Viral Loads have been quite low (Log 3.5 on the average) The most recent was 130l copies/mL Log 3.11 I don't have much to offer and I would like to stop the d4T but I am fearful of changing anything at his point. T20 Naive I don't think Prezista will work (10 PI mutations) I don't think etravirine will work (181). Possibly T20 plus MK 0518 plus Prezista (anyway) and EMT Also - I never understood why these patients have such low Viral loads. Her CD4 Count is 325 but the percentage is 11% The total Lymphs run really high = 4000. I've had several opinions but after reading about Llibre's study I decided to ask you. I apologize for the long question


RESPONSE FROM: I wonder what the patient's viral load was before starting HIV therapy. It could be she has a low baseline viral load. Additionally, her viral fitness is almost certainly very reduced. I like teh idea of the Merck integrase inhibitor plus darunavir (despite the multiple PI mutations) plus T-20. I would also consider Truvada + AZT. The latter to maintain the NRTI mutations that may be having the greatest effect on her viral fitness. If this regimen is too difficult, I would consider removing the darunavir. The alternative is to keep going with the lopinavir/ritonavir + d4T + abacavir but I also worry about continued d4T related problems. DW

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