Confused about undetectable VL and SVR
Oct 13, 2008
I am a coinfected patient with HIV and HEP C. Started hep c treatment pegasis and ribaviron on July 4th of this year. Four weeks after treatment my tests were as follows: Total Bil 1.3, alk Phosphatase 194, AST 193, ALT 184, albumin 3.4, globulin 5.1, hematocrit 39.2, wbc 9,500, platelets 326,000, tsh 1/37 and HCV RNA 610,000. I saw the doctor at week 8 and my HCV RNA was 191,000. I then saw the doc at week 12 and test results were direct bil .02, total bil 1.2, alk phosphatase 153, AST 79, ALT 83, albumin 3.4, wbc 7,600, platelet 247,000, blood urea nitro 129, potassium 4.9, HCV RNA 42,100. I am very fortunate that I have had no real side effects from treatment (occasional head ache and tired the day after the shot) and my HIV is undectable with a tcell count of 1018 as of the beginning of Oct. My question is this: at a HCV of 42,100 wouldn't that be an undetectable viral load? In the letter I got from the doc with my test results he stated "a critical endpoint is at 24 weeks where we need to see the virus test negative to have confidence you have a chance of clearing the infection". What does test negative mean? Isn't SVR meaning that after six months the virus is not showing up in the blood? I would ask the doc all of this but he is out of the office for two weeks. He did tell me that my blood work looks great, and states that I am responding to treatment well, but there is that chance because of the coinfection that I may not clear the virus (I am 1a, stage 3, grade 3 - or I was last year when I had the biopsy). Thoughts?
Thank you for all your work. I look at the questions monthly and each time I learn a little something I did not know before. I know it takes time out of your schedule, but you are doing a GREAT service to all of us coinfected individuals!!
Response from Dr. McGovern
I am so glad to hear that you check the board out monthly. That gives me the impetus to keep going!! Hopefully this answer will help others as well...
Your situation is typical of many patients. You have had a good response, but not quite as good as I would like to see. By 12 weeks, I would like to see at least a 2-log drop of virus (ie from about 600,000 to 6,000). You did not achieve that, but you are getting close.
In my practice, I monitor a patient with viremia at 12 weeks once again at 16 weeks. If you have not cleared the virus by then, I would be concerned that you will not achieve SVR - which means no detectable virus six months after stopping treatment. Alternatively, in patients with more advanced disease, I may continue to monitor at 20 weeks. If the virus became non-detectable by then, I would consider another 36 weeks of treatment based on data in HCV monoinfection (Drusano and colleagues; JID). The decision to continue this long would depend on how well tolerated your therapy has been - and you seem to be doing well.
Even if you did not have HIV (which is obviously is great shape with such a high CD4 count), I agree with your doctor that I am concerned that you will not maintain your response once you come off therapy. We call this "relapse" when your virus comes back after treatment is stopped.
It is important to document the response of your virus carefully however, since there will certainly be treatment trials of new STAT-C agents - which will all be combined initially with interferon and ribavirin.Patients who have responded to interferon (like you) will be excellent candidates for these new treatments since you probably need just a bit more potency in your treatment regimen.
You also did not mention your genotype. If you have genotype 1, I would treat you with about 13 mg/kg of ribavirin. You may want to check your dose with your physician to be certain it is optimal.
Keep your hopes up because there are many drugs coming down the pike in a few years. Stay away from heavy alcohol use; and make sure you are vaccinated against hepatitis A and B as needed.
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