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I'm afraid my (2nd) worst nightmare is coming true.
Feb 23, 2012

Hi, thank you in advance for taking my question.

I tested positive in January of 201. My CD4'S were about 400 & my viral load was about 60,000. We genotyped my virus and sensitivity tested, everything came back clean; HIV-1, no significant mutations, 98% similar to the wildtype reference. I began Truvada + Stocrin in March. My CD4'S went up to the 900's and my VL went to undetectable. Everything was stable.

A few weeks ago I started not feeling well; tired all the time and no energy. My doc pulled blood for my next check on Feb. 9th, and my CD4'S had dipped to 670 and my VL was barely detectable, at 107. I'm really concerned. My doc says we will retest in 30 days, but I'm concerned that something is wrong. I've never missed one dose of my meds, and take them at the same time every night - I'm religious about it. What do I do if the next test is still detectable and/or my CD4'S have dipped more? Is it possible to develop a resistance in only one year, even though I am so careful? What would be the next step to choosing the next regimen? I'm really worried.

Response from Dr. Young

Dear Worried,

Thanks for posting.

You're understandably over thinking your labs. If your viral load has declined as nicely as it has (from 60,000 to undetectable to 107) this means that you don't have any issues with drug resistance. A very low viral load like the 107 is usually not significant, especially if you happened to have a minor health issue (such as a cold, sinus infection, herpes flair).

It's natural to be very guarded about your CD4s, but note that CD4 absolute counts can fluctuate from day to day- both of your values are within the normal range. Before concluding that you've had a precipitous drop, take a look at your CD4 percentages and see if there's the same large drop there. If not (as I would guess), then the changes in the absolute CD4 are likely not important.

To be fair, some people do fail treatment in the first year, but usually those who have real difficulties with adherence (not you) or in whom transmitted drug resistance was not appreciated (also apparently not you).

I agree with your doctor that a repeat viral load test is in order and 30 days is a reasonable time interval (so long as you don't then have one of the things that I mentioned). We would expect that your viral load would continue to rise, say to 1000, if your virus had developed drug resistance. God forbid, if it does, then drug resistance testing helps map out the next steps in HIV treatment. Know that even in this worst case scenario, our current meds still allow for a well tolerated and effective second-line regimen.

I hope that's helpful. Be well, BY



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