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viral blip
Nov 22, 2008

Hello, I've been on Atripla since i was HIV 3 years ago, 3 months after being on Atripla i went undetectable and have been that way ever since.. my last check in Aug. i was 476/CD4 count and undetectable viral load, now just recently Nov 4th i went to 378/CD4 and 150 viral load, i was told this was a blip, should i be concerned?

Response from Dr. Sherer

Blips are common. They occur in 40% of all people on ART. However, the problem with a blip is that you can't tell if its a blip or not until the viral load test has been repeated, so there is a period of low grade anxiety until you prove that it was a blip. This low level elevation could also represent the first look at virologic failure. I suspect that you and your doctor talked about this, and that's why you are asking the website, 'should I be concerned?'....because you should be concerned, until you have proof that it was a blip, and no further additional concern is needed.

I use these common occurrences, i.e. low level viral load elevations, to do two things with my patients: 1) talk about adherence, and stare the worst case scenario straight in the face; and 2) provide reassurance.

1) In the worst case scenario, the rising viral load represents early virologic failure, and, possibly, drug resistance. I ask patients to review all that they have done to ensure that ART works for them, starting with their record of medication adherence. How have they done with ART adherence? What can they do differently? If there is a recurring problem, how can we get past it? Between the time of the 'blip' and the next test, I ask them to take this lesson to heart and do everything possible to have perfect or near-perfect adherence.

2) So now, let me reassure you. You've done great for 3 years, so you have done something right, and in particular, you have figured out how to adhere to a once daily medication. Blips are quite common, as I mentioned above, so its reasonable to think that this is only a blip. Recall also that a 3 fold change is needed before one viral load can be considered to be different from another. You may have had a viral load of 48 c/ml at your last visit ( ie undetectable < 50 c/ml). If so, a value of 3 x 48= 144 c/ml would still be no different than your last value, and your value was 150 c/ml, just barely higher than that number.

So...yes, you should always be concerned about the risk of resistance and the need to be fully adherent to your medication, but in this particular instance, you have good reason to be reassured that this is most likely a blip, and that your next value will again be undetectable.

The final part of reassurance is that, even in the worst case scenario and this IS early virologic failure and resistance, there are excellent once or twice daily regimens that are available for you that can again fully control the virus and elevate your CD4 cell count. Your doctor would, in that event, obtain a drug resistance test to help determine the best second line regimen for you.

I suggest that you talk to your doctor about your concerns and this response.


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