Insufficient progress on tenofovir, FTC and efavirenz?
Apr 1, 2005
Dear Dr Young,
I was diagnosed in December 2004 with a CD4 count of 56, a viral load of 86,000 and a CD4/CD8 percentage of 4.7.
At 23 days into treatment, my CD4 was 109, Viral load plummeted to 117, and my percentage was 6.4. I was so happy with this progress! But then, at 8 weeks, my CD4 was 122, viral load 132, and percentage 6.2.
I was alarmed that my viral load had stopped declining. How is it possible for it to drop by nearly 3 logs in 23 days, and then start rising over the next 5 weeks? I had a genotypic resistance assay before beginning treatment and no resistance was found, but isn't it possible that a tiny pocket of resistant virus has now gained a toehold and is multiplying -- thus the viral load hasn't become undetectable? What other explanation could there be for such a fast drop and then no further decline?
Also, although my CD4 count made modest gains in the past 5 weeks, the biggest gains were made before starting treatment (it jumped from 56 at diagnosis to 95 upon commencing therapy). And my CD4 percentage even went DOWN in the past 5 weeks. Does this bode badly, or is this normal, and if it is normal, why?
Thanks so much for taking the time for answering my question!
Response from Dr. Young
Thanks for your questions and post.
Looks like you started on a potent first line treatment with a high viral load. You've had a baseline resistance test (good!) and while not definitive proof, pretty good evidence that you did not acquire drug resistance. The statement that your VL was 100,000 suggests to me that the actual value was likely greater than 100,000.
You've had a huge drop (99.9%) in your viral load in less than a month of treatment. This log (percentage) drop is highly predictive of the potentcy of the drug regimen for your virus and also predicts the likelihood of long-term response. In persons who start with high viral loads, it is not unusual to see a dramatic drop in viral load over the first 1-2 months, followed by a low level viral load for weeks, if not months afterwards. (Imagine that you started with a viral load of 20,000-- if you had the same percentage VL drop, you'd be less than 50 now).
So, I'd not worry- I'll bet that the viral load will continue to drift slowly downward to the magical "undetectable" level. Keep working on the adherence and get follow up lab testing.
Good luck, good health. BY
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