Hello, I was diagnosed with HIV in Jan 2007 With a Viral Load over 100,000 and a CD4 count of 2. My physician started me on Atripla soon after. Within 6 months my CD4 count had risen to 109 and my viral load was undetectable. She was extremely happy with this progress. Upon my next visit in December I was starting to show flu symptoms and my CD4 count was down to 67. I also had only missed one dose of my Atripla sometime in August. She did not seem concerned about that at all because I was still at an undetecable viral load and told me that once I got over the flu, it should rise again. I was prescribed Tamiflu which seemed to make it the shortest case I have had in my life! Since the last appointment I had some issues with my Atripla being mailed to me and I ended up only missing one more dose due to the mail delay. I am very concerned about missing these two doses, and there was another time I fell asleep after a long night at work and didn't not take the normal midnight dose until 7 hours later. I am very worried that I've gotten off to a bad start with this. My doctor's assistant tells me I have nothing to worry about so far but I don't go back for another blood test until April. I feel better than I have in years though. Could you please let me know your professional opinion on these matters? Thank you so much!

L

You are right to be concerned, because the one important weakness of NNRTI-based regimens like atripla is that they have a low genetic barrier to resistance. Even a single missed dose is undesirable and could lead to resistance. So your doctor's assistant is mistating the real story slightly to reassure you. Unfortunately, you do have something to worry about.

Still, I would agree with your doctor's assistant's reassurance, in that the risk of resistance from these few episodes is quite small.

I disagree, however, about how to proceed from this point. In my opinion, it would be reasonable at this point for you to return to your doctor and repeat your viral load, in order to be sure that there is no evidence of viremia, early virologic failure, and drug resistance. You would be reassured by the finding that you are still well-controlled with a viral load below the level of detection...or, less likely, you would find out earlier that early virologic failure was occuring.

Finally, use these episodes to do everything you can to avoid a repitition of missed or delayed doses, and talk to your doctor - and your doctor's assistant - about how to avoid lapses in your adherence in future. I suggest that you talk to your doctor as soon as possible about these episodes, about your concerns, and about the best course of action from this point forward.