Dr. Daar,

I had hoped to hit the undetectable VL by now, but found out today that Im not yet there. A quick review of my lab results: 9/20/05 CD4 350/25%, VL 98,559. 11/21/05 CD4 288/18%, VL 43,299. Had a resistance test at this point also a few mutations (41L, 208Y, 211K, 215S, 36wt/I, 63P, 93L) but no meds ruled out most marked as maximal response, a few as susceptible. Started on Sustiva/Truvada on 12/14/05. Lab results since then: 2/13/06 CD4 521/27%, VL 539. 4/28/06 CD4 499/31%, VL 643.

So the absolute CD4 went up since taking meds, but remains unchanged in latest set although the increase in CD4% is quite encouraging. What is discouraging me is the unchanged VL in the last set (although a great initial response). My doc and I discussed options, i.e. Wait 3 more months, switch to a PI based regimen, etc. As I am leaving for 16 days in Europe on 5/19 I am not changing anything right now. My thought (and his) is to wait and see what happens with my July labs. He said that he has patients who never hit undetectable but have remained fine for years on their initial regimen. My question (finally.) how concerned should I be about this and have you seen patients that cant get to undetectable on a regimen. I should note that I have been 100% compliant never off by more than 20 mins for a dose. I have even worked out a schedule to adjust myself to European time by changing my dose time 1 hr a day.

Your thoughts, opinions and wisdom would be most appreciated.

Mike

Hi Mike,

It sounds like you were on therapy at the time the September and November laboratories were performed. Let me know if that is not true. Regardless, resistance testing suggested that you may have some early nucleoside reverse transcriptase inhibitor (NRTI) resistance but probably no significant protease inhibitor (PI) resistance. Previous treatment history immediately prior to and at the time of the resistance testing, along with other previous treatment history would be helpful to know.

In any event, it does appear that you had an excellent initial CD4 and virologic response to SustivaTM with TruvadaTM (tenofovir and FTC). The fact that your viral load did not decline between February and April is a little worrisome but I would agree that another test would be reasonable prior to making any changes. The only suggestion I would make is that it might be worth doing it sooner than later, such as when you return from Europe. If still not trending down a resistance test might be attempted and decision made about subsequent therapy. If viral load is not declining despite excellent adherence and you are unable to get resistance testing performed because the viral load is below 1000 copies/mL it would be reasonable to consider changing the NNRTI (SustivaTM) to a PI.

I agree with your doctor that many people like you will do excellent for some time even if they don't get to undetectable viral loads. The problem is that increasing resistance occurs and may limit options for the future. I still believe that if undetectable viral loads can be achieved it is an ideal goal.

Hope you are having a great trip!! Best, Eric