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Persistently detectable viral load - next treatment options?
Sep 6, 2011

Dear doctors, I hope you can help me think through my next ARV treatment move.

I was diagnosed in 8/09 with VL 8000 and CD4 360 (22%), and no drug resistance on my genotype test. I began taking Atripla in 12/09, and recorded the following results: 3/10 - VL 2800, 4/10 - VL UD, CD4 470 (27%); 7/10 - VL 95; 10/10 - VL 1060, CD4 560 (36%); 12/10 - VL 393; 1/11 - VL 87, 4/11 - VL 660, CD4 510 (31%).

Due to the persistently detectable VL, I made the switch in 4/11 to Reyataz/Truvada/Norvir. I then got labs done on 7/15: VL 301, CD4 489 (35%). VL still stubbornly detectable.

I've also tried to get resistance genotype tests done in 4/10, 10/10, and 4/11, but they always come back inconclusive (insufficient virus to run the test).

My doctor is now concerned that R/T/N alone is not working, and he suggests that we, 1.) Do another VL reading at end-August, 2.) if VL is still detectable, we either add an additional ARV to R/T/N, or go on a 1-month "treatment interruption" in order to run a genotype test. He suspects that I may have FTC resistance that didn't show up on my pre-treatment genotype test in 8/09, and would like to have confirmation before moving forward.

So, my question is, if my VL does stay stubbornly detectable, which of these options seems most reasonable? If I add another ARV, which would it be? I've also had another doctor suggest to me a switch to Selzentry + Isentress + Truvada (contingent upon a favorable Trofile test). That doctor believes the S/I/T combo could be less taxing in terms of long-term side effects, particularly as it relates to PI-associated lipohypertrophy, and that S/I/T has significant T-cell regenerating potential. My current doctor tells me he would be willing to prescribe S/I/T, but that he's concerned about the lower "barrier to resistance" for S/I compared to the Norvir-boosted PI in my current regimen, particularly for a patient with suspected but unconfirmed drug resistance, and a virus that is proving difficult to suppress.

I should add that I'm extremely compliant with my medication (likely >99% adherence, if not 100%), and that a 2x day dosing regimen doesn't worry me. I believe I'm in extremely good health - early 30s, strong organ function and healthy lipid profile, marathon runner, non-smoker and drug/alcohol free. Regularly screened negative for HCV, syphillis, gonorrhea. And of course, I hope to stay this way for a long time!

Thank you kindly for your help. I really appreciate the wisdom and support you provide in this forum.

Response from Dr. McGowan

Thank you for this question, I am sorry to hear about this vexing issue.

I have had a few patients who have had low level persistent viremia or blips. One thing to look for may be a concurrent infection (usually a herpes virus) that may be intermittently growing and may cause soem immuen activation...herpes simplex type 1 or 2 and occasionally Human Herpes virus 8. Suppression of these viruses, if active could help.

As far as changing the HIV meds, I would favor a trial intensification. I agree with your doctor that you are looking for potency now and a boosted PI regimen offers that. Perhaps a trial intensification with Isentress would help answer the question. I would not favor a treatment interruption since that has not been shown to have a good yield at picking up hidden mutations.

Best to you, Joe



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