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Follow-Up on Low Level Viral Replication Issue

Feb 13, 2011

Dear Dr. Holodniy:

Thanks for your earlier response about my low level viral replication. I took your advice and did nothing, rather than adding another drug to my Atripla regimen, such as Isentress (which would have added toxicity and possibly removed options down the road). I was tested again and found to have <50 viral load. So, that means I had three tests over three months with small viral loads (70 - September, 120 - October and 148 - January), and now in February with an undetectable viral load. My CD4 count is holding steady between 460 - 560 and 23%. Would you consider this a viral load blip, even though it seems to have lasted nearly 5 months? Is there any other explanation? Immune activation? Thanks again for your advice.


Thank you for your excellent forum.

I'm a 44 year old male who began treatment with a CD4 of 199 nearly four years ago. I have had KS, but thankfully, the lesions have all faded and no new ones have appeared since about a two years ago through HARRT-only therapy.

Until the last five months, I've been undetectable since about the first month of treatment and my CD4 percentage has risen from a nadir of about 18 to 23. My last labs show that my CD4 count is at an all-time high of 560, which is great news.

The issue is that since September, my viral load has shown as detectable at 70 (September), 120 (October) and 148 (January).

The fact that this has persisted for five months makes it seem like it isn't a blip, even though the numbers are so low and as I understand it not statistically different from each other.

Would you advise adding another drug at this time (e.g., Isentress) to my Atripla to get the viral load below 50? Or do I have to wait it out to see if viral breakthrough occurs and the VL is sufficiently high enough to conduct a resistance test, or is there another option I'm not considering?

Thanks for any advice you might have.

Response from Dr. Holodniy

Great question. Many experts would advocate doing nothing and holding the course. Others might suggest (as you did) starting something in addition to your current regimen (like isentress) or change the complete regimen to something else to get the viral load to undetectable and perhaps back off the additional drug when the viral load has been undetectable for a few tests. I am in the former camp and would like to see how the trend continues before I would make any changes.

Response from Dr. Holodniy

Thanks for the follow-up. yes, I would consider it a blip, given the very low levels of viral load. In many people the viral load level is not zero in the blood. Undetectable means below the threshold of the assay and not zero. There is more variability of the assay at the bottom then in the sweet spot, say between 1000 to 250,000, where the variability is very low. In addition, HIV treatment is not necessarily 100% effective in controlling viral replication in all body compartments, given the differences in penetration rates of various HIV drugs. So, there is likely some occasional viral replication that could spill out into the blood for some reason. In patients followed for a few years with a single or multiple blips, who continue to take their meds, there appears to be very little failure or development HIV drug resistance over the long term.

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