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Is a change needed?
Jan 10, 2008

I have been on my first regime of Combivir and Sustiva for over seven years. My initial CD4 count of 170 has risen to 1300 and my CD4% has risen from 9% to 33%. After 3 months treatment my viral load had fallen to undetectable, less than 50 copies. My last results have, for the first time, risen above the undetectable limit to 86 copies. Both my Cd4 count and CD4% have increased or remained steady since my last results. Should I be concerned and ask to be tested again? Thanks.

Response from Dr. Sherer

After seven years with such an exemplary treatment and outcome record, I might expect you to have the answer to this question. And I might just ask, what did your doctor say?

So first, congratulations to you and your doctor for this achievement. People living with HIV can draw a large measure of hope from this story. They might ask, how did you do it? How have you been able to maintain the excellent adherence needed to achieve these fine outcomes? What is your routine for taking your meds? Did you do this alone, or were there friends and family to help you with your ART adherence? If you care to write back to this website, this would be a good story for others to hear. While it's not rocket science, it's also not so easy to achieve.

My guess is that your doctor reassured you for a least two reasons. You certainly could visit your doctor sooner than usual to repeat the viral load and CD4 cell count and review your current status and recent record of adherence. The two reasons that your doctor would reassure you are: 1) there is little difference between a viral load < 50 copies/ml and a viral load of 86 copies/ml. For a SIGNIFICANT difference between viral loads, a difference of 0.5 logs, or put another way a THREE-fold difference, is required, and lesser differences are within the standard deviation and sensitivity of the assay. In other words, a significant increase from a viral load <50 copies/ml is a viral load >150 copies/ml.

The other reason not to be too alarmed is that the most likely explanation for a minor increase in viral load, i.e. between 50 and 500 copies/ml, is a 'blip' or minor increase in the viral load that occurs in 40% of people on ART, and is NOT associated with an increased risk of virologic failure or drug resistance. In the setting of a blip, common practice is to reinforce optimal adherence and repeat the viral load test. In the majority of instances, the repeat viral load is again < 50 copies/ml.

In sum, at present, no change in your regimen is needed. It has served you well for seven years, and could well be expected to do the same for another seven years or more.

You should talk to your doctor about your concerns, and you would be justified in doing so a little sooner than your next routine appointment if this is a cause of anxiety.

In the meantime, keep up your excellent record of adherence, and if you'd care to share your secrets of successful adherence, I'm sure that there are readers of this website who would be interested to hear it.

My gue


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