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Blip or Resistance
Oct 30, 2007

Dear Dr. Young

I am from India, and currently my wife, son, and myself suffer from HIV.

Regarding my wife, she started on AZT+3TC+NVP in Sep 04 with a CD4 of 83, VL of 2071, and CD4% of 13%. She has made good progress both in numbers and clinical terms. Her CD4 jumped to 327 after 1 yr, but dropped to 248 in Mar 07. During Sep 04-Mar 07, she remained undetectable. Her CD4% has remained at 18-24% during Jan 05-Sep 07.

However, in Sep 07, her CD4 dropped to 110 (248 in Mar 07), VL jumped from undetectable to 3471, and cd4% declined marginally from 24% in Mar 07 to 23% in Sep 07.

Our doctor said that 1 blip is not sufficient to change meds, and he would get another CD4 in Oct 07 to decide. Sure enough on 26-10-07, her CD4 jumped back to 242 (CD4% is 20%). No VL was done.

The doctor is now satisfied and has advised us to keep continuing AZT+3TC+NVP till the next VL/CD4 test in Jan 2008.

I just wanted to know as to how this could have happened. In 3 years, my wife has been 100% adherent, except for 2-3 delayed (5-6 hrs doses), and 1 overdose (2 tabs. instead of 1).

Response from Dr. Young

Thanks for your post from India.

In cases like your wife's, I'm not sure if I would call a viral load of ~3500 a "blip". Either this was a laboratory error (as can happen), or there is a real concern about the beginnnings of treatment failure. This is especially true since her "blip" viral load was the same (or higher) than her pre-treatment, or baseline viral load.

Viral load blips tend to be less than 1000 copies in patients who have baseline viral loads in the tens of thousands.

Because of this, and the risk of the generation of drug resistance, if she were my patient, I'd not wait an additional 4 months to sort out the issue. Rather, I'd like to see her have a viral load test in the near future. If she remains adherent to her medications and still has a viral load of ~3000, then we'd have to conclude that treatment failure has happened.

Let us know how this evolves, and best of luck to you and your family. BY



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