Question:

Your opinion would be appreciated.

I am long term survivor (diagnosed in 1985) male, 44 yrs old. I have been on meds since 1996 when my counts were around 300. My first combination of 3tc d4t failed after a year. Since then I have not experienced virological failure of any drug.

In 2004 I suffered a heart attack (following several years of treatment breaks - combination of azt, nevirapine and abacavir). Since that time I have been on this combination as backbone with some change to try to alleviate side effects.

I have been on tenofovir , but have experienced reductions in phosphorous, and was diagnosed with osteopenia in 2006- I tried this drug again and found my phosphorous levels declined once more.

My current counts are 180 (with percentage count of 9)- I am on medication for coronary heart disease, septrin and buprenorphine and pregabalin for pain relief.

I am wondering what medications or treatment options you feel I have left in order to try to raise my cd4 counts, or as my physician has suggested in order to move off azt.

I have used nelfinavir and saquinavir for short periods before the heart problem emerged and experience raised cholesterol and triglycerides from both.

Many thanks for your time

Answer provided by:

Daniel Lee, M. D.
Assistant Clinical Professor of Medicine
UCSD Medical Center
Owen Clinic

In regards to your question about raising your CD4 counts, there is not much data to suggest with any certainty that changing medications will necessarily help raise CD4 counts better than other drugs. There is some research which suggests that people on AZT regimens may have a slightly lower CD4 count due to the fact that AZT can cause lower white blood cell counts. CD4 cells are a type of white blood cell, so it makes sense that perhaps people on AZT may have lower CD4 counts. However, in my experience with patients, I have seen people with or without AZT do well in regards to CD4 cell count rises. Then, there are others who are not on AZT and also do not have great CD4 cell count responses. Unfortunately, at this time, physicians and researchers still do not have a good handle on how we can better improve CD4 cell counts in people who have seemingly remained unchanged or 'stalled' in regards to their CD4 counts. There is some research suggesting than there are better CD4 count rises with Kaletra, but this is still controversial. Of note, I presume that your viral load is undetectable. If your viral load is not undetectable, then, changing your regimen (after getting a resistance test) to get you to undetectable viral loads will help to raise your CD4 counts. In regards to changing your regimen (if that is your desire, as well as your physician's desire...), there are many newer options available now. It sounds as if, there was an attempt to switch AZT to tenofovir, but you had issues with low phosphorus levels along with concerns about osteopenia (loss of bone). An alternative may be to try to change the AZT to one of the newer classes of medications. Options include perhaps switching AZT to raltegravir or maraviroc.

Raltegravir (Isentress) is an integrase inhibitor whereas maraviroc (Selzentry) is a CCR5 inhibitor. Both are well tolerated and appear to be safe (preliminarily) in regards to not raising your cholesterol or triglyceride levels, which is of concern, given your known heart disease. Other options would be to consider switching to one of the newer protease inhibitor, darunavir (Prezista), but it would require a low dose ritonavir (Norvir), which may impact your cholesterol/triglycerides, although darunavir is probably one of the more lipid-friendly protease inhibitors. As you can tell, there are many considerations, when discussing switching or changing regimens, and I would strongly recommend that you talk with your provider about these possible options as he/she knows your medical history much better. Thanks for your question and good luck.

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