Baseline triple class resistance
Posted: Jan 21, 2008
QUESTION:
I am quite puzzled with regards to this pt. Please help/advise on how to manage this case.
RW is a 47 YO GWM referred for urgent eval for new HIV infection.
He had a Negative HIV test in May 07.
In October 07 he had Syphilis. RPR 1:512. hence an HIV test was repeated. HIV elisa was repeatedly reactive but WB was negative.
However, he had a HIV VL of 310,000 copies/ ml and CD4 792/ 46.6 %. CD8 cells were 468/ 27.5% and CD4/CD8 ratio was 1.69.
MOST INTERESTING IS HIS BASELINE PT by Virco HIV1 resistance analysis: shows: Triple calss RESISTANCE.
NRTI: 67N, 70R, 115F, 184V, 214 F and 219Q
NNRTI: 90I and K103N
PI: 10I,33F,46I,54V,58E,62V,63P, 71V, 74P,82T 84V, 93L
He is of course TX naive.
questions?
Is this his baseline Wild type virus?
Is he in acute seroconversion?
Would you tx him? Why and with what?
I am repeating the studies: requesting replication capacity, GT/PT and Tropism assay, repeat Elisa and WB and VL and CD4.
Would you advise any other tests?
Thanks
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RESPONSE FROM: 
Thank you for your post.
It would seem that your patient is one of the unfortunate ~1% of individuals who acquire multi-drug class resistant virus. For such patients, this resistant strain becomes their pseudo-wild type virus and the resistance mutations tend to persist (as compared to those with true wild type (sensitive) virus).
Since the patient had a positive ELISA and negative WB, this is a serconversion situation; one that is confirmed by having the positive viral load testing (and high CD4 count and ratios). By constrast if the patient was fully seroconverted (had a positive western blot), then by definition, this is not an acute seroconversion case.
Treatment during acute seroconversion remains controversial, but there is growing sentiment towards recommending treatment. This recommendation comes from observations that many patients proceed to needing treatment in a relatively short period of time and that treatment during seroconversion may preserve innate HIV-specific T cell immunity. The nag to this case is that there are limited options for this patient- clearly the newer classes of medications, CCR5 inhibitor (maraviroc), integrase inhibitor (raletrgravir) may have a role; the newest NNRTI, etravirine may have activity in a virus with the stated resistance mutations.
It sounds like you've done an excellent job in follow up diagnostics. I'd agree that getting the additional resistance information, including the GT/PT results, tropism assay would be essential for making a therapeutic decision. The phenotype is the only way, in my opinion, to ascertain if there are any nucleoside or PI options. Hopefully, the results will also reflect etravirine susceptibility. I favor the selection of a 3-4 drug regimen, if such a regimen can be constructed with active agents.
Let us know what you decide and how the patient fares.
BY
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