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How important is "undetectable?"
Dec 31, 2004

I've been HIV+ for 20 years now, and try to stay off meds as much as possible. I have had 3 long (1 year +) breaks from treatment, mostly to get over real bad side effects. I've been taking a new combination:Combivir/Atazanavir/Ritonavir for 6 months now. My T-4 cell count is great - now at 520 which is as high as it's been in the past 15 years. But my Viral Load hovers around the 50 line. Sometimes it's undetectable, sometimes it 53. These aren't huge differences, but obviously, we (my dr and myself) can't say that it's "undetectable," which seems to be the goal with any antiviral medications. But does it really matter? My health is good (I try to eat well and stay as fit as is realistic for an HIV+50 year old) and as I said, T-4 count is higher than in a very long time. Should I worry about this continued very low level of detectability or just chalk it up to the variability of the virus? I'm actually quite happy with this combination as there seem to be minimal side affects, at least so far. Thanks for your help. This site has always been a real help to me in deciding how to manage my health.

Response from Dr. Sherer

Congratulations on your 20 years of success with ART. You are a model to be admired and emulated by the readers of this website.

There is good evidence that the most lasting benefits of ART occur when an 'undetectable' viral load is achieved and sustained for as long as possible.

Although the threshold of <50 copies/ml best defines an undetectable viral load, there are two reasons that I am not concerned by your story.

First, though you note that you occasionally show viral loads over 50, e.g. 53, you don't mention that this is sustained, but rather that it often decreases back down to < 50. 'Blips', i.e. single values of VL over 50 FOLLLOWED BY VIRAL LOADS BELOW 50, are common, occur in 40% of patients on ART, and by themselves do not increase the risk of subsequent virologic failure.

In contrast, several studies have shown that repeated viral load values, and especially rising values, above 50 copies/ml (eg 120, then 700, then 1,400 over 3 months)- which are NOT blips - carry an increased risk of virologic failure.

In sum, your occasional viral loads over 50 sound like blips, and your excellent clinical course over 20 years also supports that.

In addition, when you do have blips, they are quite near the lower threshold of the viral load assay, e.g. 53 versus < 50 copies/ml. There is considerable variability in the assay at its lower levels, and more opportunities for signal variations in the preformance of the assay to influence the result unrelated to the real level of virus in your blood. This also is a reason to be reassured by these values.

Resistance to all med classes
Undetectable for years: what's happening now?

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