I have a patient who has been on Combivir/nelfinavir for >3 yrs. CD4/VL results: March 15, 2001): CD4=133, VL=8370 c/ml; April 23, 2001: CD4=166, VL=1889. For the past 2 yrs, CD4 has been 130-230, viral load 1800-8000. He states about 90% adherence to meds. A Visible Genetics TruGene genotype on 4/16/01 showed: M184V, L10V, M36I, I54V, A71V. Should I be concerned about this constellation of PI mutations? Would you change therapy (and to what) as his VL is still low, but patient had recent bacterial infections?
Dr. Brian Conway responds: This is an interesting question. I would certainly verify the patient's compliance with therapy, to ensure that is not a problem. This being said, I would probably intensify the PI part of the regimen with any of the range of "boosted" PI approaches that are currently available, such as ritonavir with either indinavir, saquinavir or amprenavir. Kaletra would also be an option, in light of the presence of only 4 mutations in the protease gene. If the M184V mutation is present in the RT gene, I would also consider intensifying from 3TC to abacavir (if this is consistent with the patient's regimen) to raise the barrier to resistance. I hope this is helpful to your approach to this particular patient.
