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Good CD4, but sudden jump in VL
Aug 8, 2004

Found out I was poz a year ago. Have had VL/CD4 tested every 3 months. CD4 has been pretty steady at 735/50%. VL has bounced between 7,500 and 36,600 (most recent was 24,000). Last week however, my results came back with CD4 735/50% but VL up to 750,000!! I have had no noticeable change in my health (I feel fine). My doc thinks it's an error, and had me re-tested. If the result comes back the same, would you start treatment (in light of high VL), or wait and see (in light of good CD4 count)?? Also, my early resistance testing indicated resistance to most PI's. What would your initial treatment regimin be? (I'm a 46 yr old male in otherwise very good health.)

Response from Dr. Young

Thanks for your post.

I agree that your viral load has surged at the last test. I would also agree that it's worth double checking before leaping to conclusions about treatment.

If the labs confirm the high viral load but stable CD4 count, I don't think that you have to start treatment right away. Indeed, while the high viral load has implications about how quickly your CD4s might decline, it's important to not that your current CD4s are well in the normal range and it's likely not to reach any dangerous level in the near term future. All that said, it's especially important that for persons with high viral loads who are not on treatment, that frequent (every 3 months) lab testing not go missed, since this is the best way to observe (rather than predict) your immune system health.

It's unfortunate that you've inherited a drug resistant HIV-- I'm guessing that this statement was made on the basis of a genotypic test. If there's any doubt, before any decision about medication options are made, you might consider a phenotype test. This is particuarly important for protease inhibitors, since we often have difficulty in fully predicting drug susceptibility in viruses with complex genotypes. Because of your resistance and good CD4 cell count, I'd tend to want to wait and see as long as feasible before starting on treatment.

As for a recommendation for a starting regimen, you clearly want a fully potent, three drug combo, if at all possible. You'll likely require a non-nuke (like efavirenz or nevirapine) in combination with two nucleosides (selected on the basis of your initial resistance testing). For all persons who have baseline resistance and start on medications, it's really key to have very close monitoring of the performance of the medications. This means viral load testing at 1,2 and 3 months after starting-- this is because it's possible that hidden patterns of drug resistance might emerge only after treatment is started. The only way to get a sense that this is occuring (permiting early treatment modification) is to monitor the viral load and when needed, even repeat the resistance test.

Hope this helps, thannks for reading. BY



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