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Stubbornly detectable viral load - what to do next?

Aug 21, 2011

Dear Dr. Holodniy, I hope you might be willing to help me with a frustrating problem I've been having with my meds and viral load.

I was diagnosed in 8/09 with VL 8000 and CD4 360 (22%), and no drug resistance on my genotype test. I began taking Atripla in 12/09, and recorded the following results: 3/10 - VL 2800, 4/10 - VL UD, CD4 470 (27%); 7/10 - VL 95; 10/10 - VL 1060, CD4 560 (36%); 12/10 - VL 393; 1/11 - VL 87, 4/11 - VL 660, CD4 510 (31%).

Due to the persistently detectable VL, I made the switch in 4/11 to Reyataz/Truvada/Norvir. I then got labs done on 7/15: VL 301, CD4 489 (35%). VL still stubbornly detectable.

I've also tried to get resistance genotype tests done in 4/10, 10/10, and 4/11, but they always come back inconclusive (insufficient virus to run the test).

My doctor is now concerned that R/T/N alone is not working, and he suggests that we, 1.) Do another VL reading at end-August, 2.) if VL is still detectable, we either add an additional ARV to R/T/N, or go on a 1-month "treatment interruption" in order to run a genotype test. He suspects that I may have FTC resistance that didn't show up on my pre-treatment genotype test in 8/09, and would like to have confirmation before moving forward.

So, my question is, if my VL does stay stubbornly detectable, which of these options seems most reasonable? If I add another ARV, which would it be? I've also had another doctor suggest to me a switch to Selzentry + Isentress + Truvada (contingent upon a favorable Trofile test). That doctor believes the S/I/T combo could be less taxing in terms of long-term side effects, particularly as it relates to PI-associated lipohypertrophy, and that S/I/T has significant T-cell regenerating potential. My current doctor tells me he would be willing to prescribe S/I/T, but that he's concerned about the lower "barrier to resistance" for S/I compared to the Norvir-boosted PI in my current regimen, particularly for a patient with suspected but unconfirmed drug resistance, and a virus that is proving difficult to suppress.

I should add that I'm extremely compliant with my medication (likely >99% adherence, if not 100%), and that a 2x day dosing regimen doesn't worry me. I believe I'm in extremely good health - early 30s, strong organ function and healthy lipid profile, marathon runner, non-smoker and no drugs/alcohol. Regularly screened negative for HCV, syphillis, gonorrhea. And of course, I hope to stay this way for a long time!

Thank you kindly for your help. I really appreciate the service you provide in this column.

Response from Dr. Holodniy

I favor option #1, adding an additional HIV drug. I think adding issentress to your current regimen is reasonable and see what happens. If you remain undetectable on that regimen for some period of time you could consider stopping it and staying on the old regimen.

On meds with undectable VL, low CD4%
neutralizing antibody

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