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Viral load still not undetectable
Aug 28, 2006

I was diagnosed in early March of this year. When my first cd4 and viral load measures were taken they were at a point where medication was not recommended. Three months later, my second measures were taken and my CD4 was 180 and my viral load 76,000 copies. At which time (Late May) my Dr. started me on Truvada + Sustiva. I went in 6 weeks later to have my levels measured, this time they were CD4 306 viral load 80. My Dr. wants me to be undetectable so she wanted to have my levels measured again in 4 weeks. This time the CD4 is 389 and and my viral load 100. At this time she mentioned that I might have some HIV cells that are resistant to the medication, which is why I may not undetectable. The resitance tests showed that I was sensitive to all medications. I have never missed a dose, on about three ocassions i took my meds about 2-3 hrs late. I asked her if this could have been the case and she said it was very unlikely. My question is, What could have caused the rise in my viral load? Should I talk to my Dr. about possibly changing medications? I'm due to be tested again in 4 weeks. What should I talk about with my Dr. if I am still not undetectable?

Response from Dr. Sherer

These are reasonable concerns and good questions. I urge you to take the time with your doctor to understand these tests, and this sequence of results, with my responses below.

First, your viral load did not 'increase'. In order for one viral load test to be significantly different from another, a change of 3-fold or greater is required. So from your viral load of 80, for a significant change to be recorded, a level of over 240 copies/ml would be necessary. Statistically, the results of the second and third viral load were the same.

Usually the decline in viral load from a peak level of 76,000 will reach undetectable within 3 months, but exceptions do occur. My advice is simply to be patient and repeat the viral load - there is a goood chance that you will still achieve undetectability.

Also, you should be mindful that you are very close to that threshold of <50 copies/ml, depending on the type of test that your doctor's laboratory performs, and their cut off for 'below the level of detection.'

Studies in the US of people with chronic infection who have never been treated suggest that 9% have a resistance mutation to one or more drugs. It is possible that this is accounting for your lack of complete suppression. Your next values should help to define whether this small risk has contributed to these events, i.e. you would expect your viral load to continue to rise, and a resistance test (after the VL is above 1,000 cop/ml) would be expected to show a resistance mutation to Sustiva or another member of the regimen, e.g. FTC.

If this were to occur, there remain many potent, simple regimens that are available to you.

As above, please share your concerns and these thoughts with your doctor.


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