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Viral Load Not Going Undetectable
Jan 19, 2004

Hi Dr. Young, Dr. Wohl, and Dr. Pierone,

In mid-October I started treatment with Combivir + Kaletra. When I started my CD4/percent/viral load was 290/19/150,000. About 2.5 weeks into treatment my counts were 400/19/900. Recently my doctor did another viral load and its now at about 1000, so roughly the same. Is this bad? How quickly should it become undetectable? Should I be concerned?

Also, I have had fatigue which my doctor attributes to Combivir. He wants to switch me to Epivir + Viread and keep on with Kaletra. I have held off because I often read of the importance of the first regimen and how you shouldn't make switches unless the viral load is undetectable. Is this true? When is switching okay? Why is the first regimen so important and different from the others? Should I even switch? The fatigue is unpleasant but I'm still able to go to school and live life fairly normally, just tired all the time.

Thanks for the info. I really appreciate your help. This website is a source of tremendous reassurance.

Justin

Response from Dr. Wohl

Dear Justin,

I have to say, I have not cheated by looking at any answers my esteemed colleagues may have provided. Your response has really been pretty remarkable. Your viral load is down more than a hundred fold and immunologically you are a complete success. Overall I give you a silver medal. Not bad at all.

The low level of virus is understandably a concern. This may well be virus that is being released into the circulation from infected cells and not multiplying resistant strains. I suggest your doc get a genotype resistance test before any switches. Your viral load may be too low but maybe not - it is worth a try. I predict your virus will be 'wild type' meaning no resistance present. If so I'd probably keep on with what you are doing except:

1) I would make the change to tenofovir+3TC. What you have heard about regarding the importance of first line therapies is correct. THe first shot may be the best as subsequent therapies usually have to deal with the resistance that developed with earlier regimens. That is not your situation. This swap would still be considered your 'first' therapy and may make you feel better. Certainly, it should be just as powerful as your current regimen.

2) I would consider seeing what taking 4 Kaletra twice a day does. IF you can tolerate/afford this, it may bring the viral load down. If it doesn't after 3-4 weeks, you can always go back to the usual dose.

Let us know how it goes.

Thanks,

DW



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