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Treatment without Genotype
Jun 4, 2011

I was recently diagnosed and had the first lab results with CD4 480 and VL 310. Genotype could not be performed due to low VL. My doctor seems to be in the school of starting treatment early. Is it safe to start a treatment without genotype result?

Response from Dr. Young

Hello and thanks for your post.

I'm with your doctor in the benefits of treatment, though I'm not necessarily in agreement that a CD4 count of 480 is "early", it's just in keeping with current US treatment guidelines.

On the other hand, you do appear to have a very low HIV viral load. Since low viral loads tend to predict slow CD4 decline, at face value, this factor might safely allow you to monitor your CD4 count for a while to see how rapidly it declines (if it does). One detail to mention is that in cases like yours, I like to do an alternative test of HIV viral load, called b-DNA testing. This test uses an alternate measurement to quantitate viral load; some viruses are not detected (or measured) well by RT-PCR, but are by b-DNA.

Now to your question, starting treatment without a genotype can be done (it's done that way for most patients around the world), but less preferred, as about 10% of US patients have some degree of transmitted HIV drug resistance. One needs to be mindful of this fact in choosing a treatment that avoids the more commonly transmitted types of drug resistance (namely NNRTI resistance). Therefore, I'll tend to avoid first-line treatment with NNRTis, in favor of regimens with protease or integrase inhibitors, as significant transmitted resistance to these medications is very rare.

I hope that helps, BY



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