Sep 24, 2005
Earlier this year he switched from Trizivir/Sustiva to Trizivir/Viramune due to CNS side effects from the Sustiva. His CD4's have always been in the 300-350 range and never above. During his most recent visit (yesterday) we received startling news, his CD4 count was 515 but his VL now 34,000 copies. Again, please keep in mind that he had CD4 350 and VL undetectable only three months ago (his last doctor's visit).
He has 100% compliance in taking his meds, eats healthy and works out every day.
The doctor ordered another blood test yesterday and should have results back in 2 weeks.
What are chances this is a lab error? My partner mentioned that when the "new" doctor initially attempted to locate his file, she couldn't even find it! ... perhaps another patient's file (??)
If not an error, given that my partner takes his meds faithfully (1 Trizivir /1 Viramune 9am and 1 Trizivir/1 Viramune 9pm), what could possibly cause such resistance in a short period of time where the CD4 goes up dramatically along with a very sizable VL increase (i.e. undetectable to 34,000 copies)? I thought as the VL goes up the CD4 drops respectively (i.e. inverse relationship). I also thought if one were developing reesistance it would more than likely start out as blips (<50 to perhaps 1000 copies) and not an explosion of 34,000 copies.
Lastly, if by chance the results were correct, what other class of meds would you suggest if this was not an error (I'm assuming a genotype would be done)?
Sorry for so many questions. This just really threw us for a loop since everything was smooth sailing up to this point.
Response from Dr. Young
Thanks for your post.
Your partner's situation does seem unusual to me. I wouldn't have predicted that a simple switch from efavirenz (Sustiva) to nevirapine (Viramune) would have precipitated a loss of viral control. Furthermore, as you point out, it's unusual to see viral loads go from 0 to tens of thousands without some glimpse of increase first.
Certainly before going for the loop-de-loop, I'd want to see a repeated set of labs. Also, let's be sure that he didn't have a new or acute infection (like sinusitis or a herpes flair)-- things that can cause a spurious increase in viral load.
Lastly, though I hope and believe that this won't be necessary, there are plenty of treatment alternatives that should be fully suppressive in the event that there really is treatment failure. Of course, getting drug resistance testing at this point (if confirmed) would be very important, both for the immediate treatment decision, but any future treatment decisions. As I've stated in other posts, if finances permit, I obtain both genotypic and phenotypic tests at this point, in large part because of the variability of the actual resistance among viruses (even those with identical genotypes).
Let us know how this turns out. Thanks for writing and good luck. BY
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