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Still not undetectable after 4 months, should I change?
Sep 4, 2003

I started my first meds (Tenofovir, 3TC, Efavirense)four months ago and I'm not quite undetectible yet. My VL was 67K and rising and CD4's were 310 & declining so I started meds. VL=1,130/CD4=310 after 2 weeks, then VL=301/CD4=336 after 1.5 months, now VL=195/CD4=340 after four months. Is it time to get more agressive by adding a fourth drug or should I stay the course on my current cocktail? My Doc recommends staying the course and testing again in six weeks.

Response from Dr. Young

I'd be concerned that something isn't working the way that we'd expect with a persistent viral load of 200 when your starting viral load was an "average" value of ~70,000.

Firsly, making sure that you're not missing doses or have a concomitant infection would be essential-- simple things like sinusitis or a herpes flair could easily explain your low viral load, and as such, I'd call the discussion closed and would continue to monitor things.

If this is not the case, then further exploration seems warranted. The approaches that your doctor and you have offered are both reasonable, but represent different ends of the options. One would be to intensify the treatment regimen, but adding a forth drug, as you've suggested-- which drug? tough to answer without more details, but some have added a forth nucleoside (you could consider AZT, ddI, d4T, but not abacavir- because of drug interactions) or perhaps add a protease inhibitor. Adding a forth drug exposes you potentially to additional side effects, but in previous studies has helped those with persistent low level viral loads.

A wait and see approach, is also not unreasonable, though I usually repeat things on a monthly basis in this situation (mostly a stylistic difference, I think). It might be possible in this later situation to explore getting ultrasensitive drug resistance testing-- Virologic can now reliably obtain resistance information on samples with viral loads as low as 500 and if specially requested, will try to get data on even lower viral loads.

Hope this helps. Good luck. BY



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