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Insufficient progress on tenofovir, FTC and efavirenz? Thank you and follow up
Apr 2, 2005

Hi Dr. Ben,

Thanks so very much for your careful answer to my question. You clearly have a wonderful cyber-bedtime manner! Can I bother you with a couple follow up details?

You mention that you suppose my viral load was somewhere higher than 100,000 -- perhaps because for some tests 100,000 is the upper limit that the test can resolve, correct? Actually, my two baseline tests showed VL of 86,500 and 99,500. It was me who rounded up to 100,000. Second, you suggest continuing to work on adherence... My adherence has been perfect, even anal, with all medicines taken at precisely the same time each day. With perfect adherence and viral loads below 100,000 (though only a hair below) is it still common for viral loads to fall precipitously and then slowly drift around until eventually falling below the magic number, 50?

Finally, I wonder about my CD4 count. At baseline, I had a count of 95, and a % of 5.5. At 23 days, I was up to 109 and a % of 6.4. At wk 8, I was up to 122, but my % had FALLEN slightly to 6.2. Does fall in percentage bode badly, or is this normal, and if it is normal, why?"

Again, thanks for your time and careful, compassionate replies. Greetings from London,

J.

Response from Dr. Young

Dear J- Thanks for your follow up and complements. Even a few positive words are very meaningful.

Recalling your viral load response-- yes, it's not too unusual to see viral load hover just above the detectable level for some weeks after an initial brisk response. Indeed, the reduction in viral load is known to take a biphasic shape; first very large (or steep) followed by a longer second, slower phase of decline. I'll wager that you're probably in this second phase, but also expect that within a few months will be below level of detection.

As for CD4 count, despite such rapid improvement in viral loads, it is usual to see CD4 changes lag behind. Perhaps some spin here is indicated-- after only 8 weeks, you've had a ~25% increase in both your CD4 absolute and percentage. These increases are reproducible, insomuch as being about the same on both the week 3 and week 8 lab tests. I wouldn't put too much stock in the differences in 6.4 and 6.2%-- such small changes are well within the usual variability of the tests.

Overall, patients who begin on the regimen that you have (or other contemporary regimens) have seen ~200 cell increases within the first year of treatment. Based on your initial viral load declines, I see no reason why your counts also shouldn't be on this trajectory.

Good luck, have a happy and healthy Spring. Keep us informed on your progress. BY



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