Important note: Information in this article was accurate in 2006. The state of the art may have changed since the publication date.I'm trying to decide when to add additional meds....
I have been infected since 1986. My most recent regimen consisted of Trizivir and Sustiva. I took these meds for about 4 years and finally dropped the Sustiva due to continued side effects. I continued taking Trizivir for another year and then dropped AZT, switching to Epzicom only. My t-cells are now 372 and VL is 2732. They have hovered in this range for the last 3 to 4 years with one VL spike to 21,100.
Geno/pheno tests show that I am resistant to all of these meds with some resistance to protease inhibitors also - I took Crixivan almost 10 years ago.
At this point in my treatment my Dr would like to see a non-detect VL and has suggested that I add Reyataz and Ritanovir to the Epzicom that I take now. She feels that a prolonged elevated VL will result in virus mutations. I'd like to extend my options as long as possible and have talked to her about continuing with the status quo - Epzicom. My VL and T-cells don't seem alarming and I'm not sure when to make a change. Do you have any insights?
If I understand your geno/pheno results, you have lost the NNRTI class that contains Sustiva along with most of NRTI's (someone who is resistant to 3TC and AZT and abacavir in Trizivir is usually cross-resistant to all the other NRTI's). Plus there is some residual PI resistance from past Crixivan. Therefore, it seems unlikely that it is currently possible to create a regimen with three fully active antivirals.
In this case, adding Reyataz boosted with Norvir to Epzicom will probably initally drop the viral load to undetectable but then the viral load will rebound. This then will add Reyataz resistance to your geno/pheno.
While I agree with your doctor that prolonged uncontrolled viral loads may lead to increased risk of more mutations or some opportunistic infections, your numbers are not that bad. And if you are already cross-resistant to all the NRTI's, there is probably no harm in staying on Epzicom, which will maintain about 1/2 a log drop in viral load.
Then I would wait for access to one of the new classes of antivirals that are coming into their final stages of testing - integrase inhibitors or entrance molecule blockers or TMC-125. This would allow the creation of a much better combination with the Reyataz.
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