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Low level viremia despite treatment

Jun 23, 2013

Dr. Holodniy,

After being undetectable (VL<20) on Atripla as my first regimen for almost 2 years, my latest blood tests indicate low viremia (without increase), though I am 100% adherent

Before Nov 2011: VL<20 Nov 2011: VL 55, CD4 517, 26% March 2012: VL 55, CD4 560, 35% June 2012: VL 24, CD4 555, 29% Oct 2012: VL 50, CD4 630, 37 % Feb 2013: VL 24, CD4 765, 30%

What do you make of these numbers? I am worried about emergent resistance and failing treatment, and rather confused and anxious. Time for a switch or intensified treatment?

Response from Dr. Holodniy

I certainly understand your concern. Unfortunately the data is controversial as to the meaning of such persistent, but extremely low viral loads, and then what to do. When the viral load detection limits were around 50 copies, and everyone was undetectable and < 50, we never cared. Now that the viral load tests can measure below this threshold, many people are persistently detectable. A minority percentage of these will demonstrate virologic failure, and many will not. We don't have a good handle on what all the variables are that predict who will and who won't fail. The intensification studies for this situation have not provided a clear answer that such strategy works. Given where your CD4 count and percent are (both in the normal range), I would be inclined to stay the course, but following things very closely.

1 year ART, still detectable viral load?

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