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Can't reach undetectable levels

Apr 20, 2013

Dear Doctor

Before starting treatment I had a VL of several million.

I started on Truvada, Reyataz, Norvir, but as it gave me severe yellow eyes my Doctor after 10 months moved me on to Truvada, Prezista, Norvir, for the past 2 months or so.

My problem is now after a total of 12 months of being on treatment, my VL load is not becoming undetectable. The last three tests have been 110, 160 and 97.

My Doctor now wants to add Isentress (twice daily) to my current treatment of Truvada, Prezista, Norvir.

I'm extremely worried that this appears to be a very heavy load of Meds.

Is there any alternative? Is there any harm in waiting some more months to see if it becomes undetectable or given I am 12 months on treatment is it just not going to happen on the current Meds? Do I run the risk of building up resistance/virus mutation at these Vl levels if I don't add Isentress?

I also dont understand that after my initial diagnosis and having a resistance test at the time, nothing appeared. Why then am I unable to reach undetectable levels?

Thanks in advance for your help

Response from Dr. Young

Hi and thanks for posting.

The key thing to your labs is that you started with a very, very high viral load. For people like you, it can take a very long time to reach the undetectable benchmark, even though your viral load might have decreased by huge amounts.

For example, if your viral load was 1,000,000- decreasing to a viral load of about 100 is (1,000,000-100)/1,000,000 or about or 99.99% (4 log10)- a very substantial and excellent response by any measure. It might take many months to achieve that last bit of decline to undetectable levels- in my opinion, there's only limited concern that your at risk for developing resistance.

If your viral load had been more typical, around 50,000, a 99.99% decrease is well below undetectable levels.

So, I'd be ok with continuing to on your regimen, but since it's already been a year, I can appreciate the desire to try something different, or something more. Adding Isentress (raltegravir) to your regimen would be a well tolerated next step.

Stay in touch and let us know how things work out. BY

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