Hi Dr. Daar,

I last wrote you just before I left on a Meditarranean cruise with this same concern. Well, I added a boosted PI and Im a bit frustrated that I cant seem to get my VL down to undetectable still and am at a loss at how best to proceed. A quick review: Tested positive 8/24/05 Sept 2005 CD4=350 (25%), VL=98,559 Nov 2005 CD4=288 (18%), VL=43,299 Dec 2005 -- Started on Sustiva/Truvada (first HIV meds ever) Feb 2006 CD4=521 (27.4%), VL=539 Apr 2006 CD4=499 (31.2%), VL=643 June 2006 Added boosted Reyataz to intensify my regimen Aug 2006 CD4=576 (30.3%), VL=111

I had resistance testing done in Nov 2005 and repeated in May 2006. Both results were the same: NRTI mutations- 41L, 208Y, 211K, 215S NNRIT mutations NONE PI mutations 36I, 63P, 93L

So, it seems to me that with a PI, NNRTI and 2 NRTIs that I should be undetectable of course I am happy that I did have what seems to be a significant drop in this last set of labs AND, Im down about 99% from my highest VL. Although, it isnt as big a concern to me Im disappointed that my cd4 seems, basically, unchanged since February (but double my pre-medication level). My adherence has been 100%. I currently take all my meds at the same time (before bed), with a snack (usually a granola bar and 4 crackers with peanut butter or cheese). No real side effects to speak of although my latest Total Bili was 2.0 but I expected that with the Reyataz.

My ID doc and I decided that we would repeat the labs in Sept -- to give the Reyataz a full 3 months. I have no idea what I should do if I remain detectable. My questions: 1 Am I just being too impatient? Everything I read points to that NOT being the case. 2 Any thoughts on possible courses of action? 3 Are there people that simply dont get to <50 for some reason? (At least Id finally be undetectable under the older assay <400)

Sorry for being so long-winded here but any thoughts you can give would be most welcomed.

Thanks for all you do here, Mike

Hi Mike, Thank you for the follow-up. Based upon the resistance testing it is possible that you did acquire some resistant virus that could partly attenuate the activity of the NRTIs. Nevertheless, you have had a good response thus far. I would agree with your provider that you should wait at least another viral load measure before mading any changes since it does appear that things were trending down on Reyataz with ritonavir (VL-111). It may be that you are on the way down. If you do not get to undetectable levels on this regimen I would consider a few things. First, make sure that you are not taking any drugs that might decrease gastric acidity and impair absorption of Reyataz/ritonavir. If this is not the case you should then discuss with your primary provider possibly switching PIs. It is possible that some of the potency of Reyataz could be attenuated by the fact that you are on two drugs that can reduce its levels, both sustiva and tenofovir. Hopefully your viral load will go to less than 50 copies and you won't need to make any additional changes.

With regards to whether some treatment nave individuals never get to undetectable. It certainly happens but in most cases it is because of either not taking the medications appropriately or having acquired drug resistant virus. While the latter may be true in your case, the level of resistance is not sufficient that I would expect it to prevent you from achieving this goal once on the right regimen.

I would not be disappointed with your CD4 count since the numbers are great and you should not be at risk for developing HIV-related complications with T cells this high. In addition, with good viral suppression I would expect them to slowly increase over the years.

Best, Eric