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Very concerned about rise in viral load.
Jun 8, 2009

Hello there. I was diagnosed in July of 2006, at which time I had a CD4 of 90, and a viral load of 5000.

I immediately started Truvada/Sustiva, plus Sulfamethoxazole as prevention for PCP.

After a few months, my viral load was "undetectable" and my tcells had risen to 124.

In July of 2007, I was undetectable and CD4 had risen to 190.

In July, 2008 I was still undetectable, and CD4 rise to 200.

I just got lab results back today (April 21 2009) and my CD4 has risen to 325. However, my viral load has also risen -- to 184, which is worrying me greatly. I am with a program, and do not see the same doctor every time. Today's doctor was not very forthcoming with information, and just sort of shrugged his shoulders.

Does a rise in the viral load of this (small?) magnitude signal oncoming drug resistance? I have been 100% adherent to my regimen since I started. I have never missed a dose. However, I do travel internationally for my job a lot, and frequently fly to places like Australia. (From California.) And in the other direction, to Europe. My doctor had told me to always take my medication before I go to bed, by whatever time zone I am on. However, when traveling to Australia or Singapore, this can "technically" mean an 8 to 12 hour delay in taking meds. Of course, on the way back, the trend gets reversed. Could this be responsible for my change in viral load?

I am very anxious about this, since I had maintained "undetectable" status for so long. I was also worried about what seemed to be a slow rise in my cd4 -- as it seems that going from 90 to 325 over a 2 year and 8 month period seems slow.

Should I be worried about the onset of drug resistance? I have never had any opportunistic infections. Or is there another regimen which would be better for me?

Thank you so much. My next doctors appointment is not for three weeks, and I am freaking out!

P.S. I am still on Sulfamethoxazole. Should that not have stopped at CD4 200 or thereabouts?

Response from Dr. McGowan

Thank you for your post.

Since you have been completely adherent with your meds and have always had an undetectable viral load (for years), having a one time viral load between 50 and 400 may have no effect on the durability of your treatment. The key is to have it repeated to be sure that it is undetectable again. A single detectable, low level viral load is called a blip. Blips can be due to: lab error, having a recent illness with fever, a recent (within 4 weeks) vaccination, or an outbreak of a chronic/recurring condition such as herpes simplex. The test should be repeated as soon as possible, unless you had an identified condition, such as a vaccine in which case it can reapeated after 4 weeks.

I agree with your doctor that the best thing to do while traveling is to shift your doses to the new time zone and back (especially if you plan to be in a new time zone for a few days or more). A slight one time shift in timing for the flight is not enough time to allow the virus to "wake up" and start copying itself (that may take several days).

You CD4 count increase has not been bad since you started at a low count. If your viral load remains undetectable with repeated CD4 counts above 200 for 6 months than PCP prevention treatment can be stopped.

Best, Joe



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