Question
My friend has neurological problems on Atripla…
5 October 2009. Related: All topics, Changing treatment, Living with HIV long-term, Opportunistic infections, Resistance.
I’m worried for a friend. He has been HIV-positive for a little over 10 years and started taking medication nearly 2 years ago. He’s been taking Atripla (efavirenz + tenofovir + FTC) since May 2008. His CD4 absolute count has gone from 89 in March 2008, up to 170, then has fallen steadily to last months figure of 51. His CD4 percentage is 4%. The last count before that was 127 and 6%. His viral load is undetectable. He is also taking Septrin (960mg daily).
He had a lumbar puncture done about March 2008 and he wasn’t diagnosed as definitely having PML but they said it was possible.
I’m seeing a worsening in his cognition – speech slurring, memory loss, forgetfulness, unsteady on his feet – but his consultant says there is no need to repeat the blood tests and to just wait until next month.
Should they be doing more tests? What should I say to his consultant – should I be worried?
Answer
Hi
I think you are right to be concerned about your friends situation bacuse both his CD4 count and CD4% had been steadily falling and they are now low.
Even though his viral load is undetectable, his symptoms suggest a neurological problem, even if this is not PML.
The change in symptoms may or may not be related to HIV medication, or they may be an indication of a more serious medical problem. His doctor should perform a detailed work-up to find out the cause, including scans for neurological problems. If this isn’t being done I would seek a second opinion – ie ask to see a different doctor or see a doctor at another hospital. Please call me at i-Base on the phoneline if you would like to talk in more detail.
In terms of his HIV treatment, two things could be happening. Either his current treatment is not getting through the blood-brain barrier to control HIV in the brain or his current combination worked for a while but then developed resistance in the brain compartment (called CSF – cerebral spinal fluid).
There has been a focus on brain penetration by antiretroviral drugs and some studies report that this may be important for some patients.
We reported a French study at this link in patients with PML who switched to multiple drug combinations including those which get into the CSF.
Researchers involved in a US study called CHARTER has produced a table rating for different drugs. Although this is not definitive, it could be used as a basis for changing your friends combination. The slides from this presentation at ICAAC are posted to the NATAP site here.
Table: Estimation of penetration-effectiveness in CNS (central nervous system)
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