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Intensify early treatment?
Oct 26, 2004

I tested positive in March 2004, CD4 262, Viral Load 61,000. Two months later, in May, my CD4 was 317 and viral load 334,000. I'm 21 years old, and I'm not sure how long I've been infected--the maximum amount of time could be 4 or 5 years. Regardless, it seemed pretty clear to my doctor and I that I was not in the early stages of infection, and treatment was necessary. I started Kaletra, Viread and Emtriva in May immediately following that 334,000 viral load result. At four weeks (in June) my Viral load was down to 1800, but six weeks after that (at 10 weeks on meds total) it was only down to 578, and four weeks after that (fourteen weeks total) it had only gone down to 401 copies. Obviously, I had a very good initial response to treatment (in the first 4 weeks) since my viral load plummeted from 334,000 to 1800. In fact, even if the 334,000 was a 'blip' or error, going from a viral load of 61,000 to 1800 copies in 4 weeks is pretty good. But the fact that the numbers haven't gone down much after that is a bit worrisome to me. I've been extremely adherent to my meds, so I'm not worried about drug resistance that I may have brought upon myself. Instead I'm worried about the possibility of hidden resistance that I may have had before I even started the drug regimen. I had a genotype test before I started meds and it came out fine, but that test was really meaningless because if I had any pre-treatment resistance, it was probably a small sub-population. Basically, i'm wondering if it would be out of line to demand a phenotype test and, at least, the temporary, if not permanent, addition of a fourth drug at the next visit (in a few days), in order to force me down to undetectable. I know that with people who start with my initial viral loads, it is not uncommon for it to take 6 months to reach undetectable, but I feel like at 14 weeks, I should be easily below 400 copies, especially with the extremely good response I had within the first month of treatment. And with the rate of decline of viremia itself declining at the rate it is each month, it seems unlikely to me that I could possibly reach less than 50 copies at 6 months.

Basically, I'm asking (a) how bad you think my numbers really are, and (b) whether I should demand a phenotype test at the next visit. Money really isn't that much of an issue for me, so I'm willing to pay for it, even if insurance is not.

Response from Dr. Young

Thanks for your question.

I don't think that it's time to throw in the towel, so to speak, on your regimen. For persons with high initial viral loads it can clearly take longer to reach the magical "undetectable" level. What is clear if you look at your numbers is that you have a nearly 99.9% (3 log10) reduction in viral load. This usually predicts a very good long-term response to treatment.

Yes, there is the concern about "minority variant" drug resistance in every person, meaning that all drug resistance tests have the limitation in the difficulty in measuring small populations of drug resistance in a larger population of drug sensitive virus. Nevertheless, your initial test is certainly reassuring in this regard. Additionally, obtaining drug resistance testing in persons with viral loads between 500-1000 can be difficult and below 500, the tests generally cannot be done (because of methodological issues).

So, in the end, I'd continue to work on adherence (including issues related to dietary restrictions) and continue to get laboratory monitoring. If you were my patient, I'd probably not intensify therapy at this point, but to watch things closely. The regimen that you're currently taking should be very potent and quite effective, even in the face of limited drug resistance.

Let us know how things turn out, and good luck. BY



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