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Resistance and Viral Load
Jun 12, 2008

Just tested positive. Seems I have been positive for about three years based on the prior negative test. My VL is 8,000 copies and CD4 count 502 (18.6%). My conventional wisdom tells me to wait, but the low percentage, my age (mid forties) and my level of overall anxiety over the possibility of declining health tells me to err on the conservative side and start meds. My uneducated guess is that the lower the viral load is at the time of starting meds the better the chances to get to undetectable for a long time; but on the other hand I worry I may be putting myself in a situation in which I facilitate resistance too early. As I consider the proper course, I wonder if there a relationship between the amount of the viral load at the time you start HAART and the success at viral suppression and the likelihood that an early start will facilitate the virus becoming resistant to the first drug regimen. Any thoughts or data on this?

Response from Dr. DeJesus

It is very interesting that you have all these concerns in 2008. Thankfully all those issues have been carefully thought out throughout the years by many experts based on the body of data that have been generated by multiple clinical studies. The good newswe have relatively good answers for all those questions.

Your educated guess it right in terms that the lowest the viral load at the time that you start therapy the easier it is for your viral load to become undetectable. But regardless what viral load you start with (high or low), once you become and remain undetectable, the likelihood is that you will continue to be undetectable, and that you will not develop viral resistance; so you do not have to worry about that. Remember, for you to develop viral resistance, you have to have a detectable viral load. With the regimens that we have available today, which are very good, more than 95% of patients that take them right, are able to able to achieve and maintain a viral load undetectable, hence no chances that your virus will become resistant!

In other words, resistance does not occur by itself if your viral load remains undetectable. If your viral load increases, once it was undetectable, then you can develop viral resistance. The main reason why your viral load may suddenly become detectable, after virologic suppression, has to do with how good you take your meds. So, in a nut shell, if you start meds, and you take then right (not missing dosages), the likelihood (>95%) that you will become rapidly undetectable, and that your virus will never become resistant, as long as you take your meds with good adherence. There are a few exceptions, for example, if you become re-infected with another HIV strain that may be resistant to the medications that you may be taking. So, safe sex remains a must for all patients!

In the past few years HIV treatments have become very safe, and new data generated from epidemiological studies are staring to demonstrate that patients starting therapy at t higher CD4 counts (>350 cells/mm3) may suffer from less medical complications at a long term. HIV viral loads have also been found to play an important role in predicting future outcomes, with patients with HIV viral loads very high (i.e. >100,000 copies) at greater risk for disease progression. With the data that we have available so far from clinical studies we can make a firmed recommendation that for those patients with CD4 count >350 cells/mm3 (but below 500 cells/mm3) and HIV viral loads elevated (i.e. >100,000 copies), initiation of anti-HIV therapy should be considered.

There is a very strong possibility that patients with even higher CD4 counts (>500 cells/mm3) and lower HIV VL (<100,000 copies) may also benefit at a long term from initiation of anti-HIV therapy. I personally believe that those patients, like you, will benefit from initiation of therapy, but there is no definitive clinical data from studies to confirm this theory. You also mention your age and the anxiety that is causing you not starting medication. Considering all these factors, I would start treatment earlier rather than late.

Maraviroc, Isentress & Atripla?

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