A patient started HAART three years ago, with d4T/3TC/nelfinavir. He had not received previous ARV therapy. His HIV RNA has been persistently below 50 copies. He underwent a one month STI and after 15 days of drug suspension, his RNA was 3000 copies/mL, and plasma genotype shows the presence of the M184V and T215Y mutations. How should this be interpreted? Should therapy be changed when it is reinitiated?
Dr. Brian Conway responds: This patient is very interesting. The detection of the M184V/T215Y mutant so rapidly after the discontinuation of therapy may well represent the emergence of a pre-existent strain with primary drug resistance. Although the combination of d4T/3TC/nelfinavir worked in the first place, it might be "tempting fate" to re-initiate the same regimen. A simple, practical approach might be to restart with d4T/ddI/nelfinavir, given that the availability of VIDEX-EC allows for the easy administration of the ddI.
