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Changing HIV Treatment: What to Do if Viral Load Rebounds

October 1, 2015

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This is an adaptation of an educational booklet published by HIV i-Base, a British treatment activist group, in February 2015. The full version of the booklet is available on their website, as well as in PDF format.

Table of Contents

Reasons to Change Treatment

There are two main reasons to change treatment.

  1. If your viral load never became undetectable.
  2. If your viral load was undetectable but started to rise again (viral rebound).

In both cases your treatment could have failed.

This booklet is about these two situations.

A third reason to change is if you have side effects.

It is always important to talk to your doctor about side effects. Changing treatment is usually easy. It can really improve your quality of life.

A separate guide is available if you are changing because of side effects.


Why is viral load important?

A viral load tests checks how well your treatment is working. When you are on treatment this test is often a more useful than your CD4 count.

If you are starting treatment, it can show whether the drugs are working.

If you are on treatment is shows whether treatment is still working.

How accurate are viral load tests?

In the UK, viral load tests have a cut-off of 20, 40 or 50 copies/mL. Below this level, viral load is called undetectable.

The differences between these tests are not significant.

It is common for viral load to be less than 5 copies/mL

However, viral load tests have "a three-fold margin of error."

This means that a result of 50 could really be anywhere between 16 (3-fold lower) and 150 (3-fold higher). A result of 500 could be anywhere between 50 and 1500.

This is why it is essential to confirm an unexpected result.

If Your Viral Load Never Became Undetectable

How quickly should viral load become undetectable?

When you first start treatment, viral load drops quickly.

Many people get undetectable within the first month and most within three months. Some people take longer.

The time it takes to get undetectable depends on several things:

  • Your viral load when you start. The higher it is, the longer it will take.
  • Which HIV drugs you use. Integrase inhibitors reduce viral load faster than other meds.
  • Adherence. Drugs can only work if you take them. If you take your meds on time, viral load comes down more quickly.

Viral load should drop by at least 90% in the first month. This is sometimes referred to as 1 log (see Table 1 below). If not, your doctor will ask you about adherence and may take other tests.

If viral load is still detectable after 3-6 months, it is normal to change treatment.

What is second-line treatment?

Second-line is the name for your second combination.

If this second treatment fails, your next treatment is called third-line.

How long should I wait?

This will depend on your individual situation.

It will depend on why treatment may have failed and on the results of other tests.

Table 1: Log Scales (A Log 10 Scale Is a Multiple of a Factor of 10)
1 log = 10 1.5 log = 30 1.7 log = 50
2 log = 100 2.5 log = 300 2.7 log = 500
3 log = 1,000 3.5 log = 3,000 3.7 log = 5,000
4 log = 10,000 4.5 log = 30,000 4.7 log = 50,000

What to Do if Your Viral Load Rebounds

Getting a second test

  • A low-level rebound may not be serious.
  • It may be a lab or test error.
  • It may just be a small blip that goes back down again.

This is why it is important to repeat the test.

The second test should be taken when you get the detectable result.

Don't just wait for weeks or months until your next routine test.

If the second test is still detectable this is a "confirmed viral rebound."

Viral Load Blips

Viral load blips are common.

A blip is when viral load goes above 50 for a short time and then drops back down. See Figure 1.

Most blips are not detected because viral load is only tested twice a year in people on stable treatment.

Blips can be defined as an increase from less than 50 to 200, 500 or even 1000. Most blips are under 200. Blips can be caused by other infections, such as flu or herpes, or a recent vaccination.

Some blips are just lab errors.

Figure 1. Viral Load Blips

Figure 1. Viral Load Blips

A single blip above 50 is common. It doesn't mean you need to change treatment.

A blip is usually undetectable again on the confirmatory test.

Confirmed Viral Rebound

If the second test shows your viral load is detectable at a similar or higher level -- and you have been taking your meds -- this confirms viral rebound. See Figure 2.

It is likely you have started to develop resistance to some or all of the drugs in your combination.

Most guidelines recommend changing treatment.

This is because HIV can develop resistance even when viral load is relatively low (between 50-500).

Figure 2. Viral Load Rebound

Figure 2. Viral Load Rebound

If the second viral load test is still detectable, and the person has been taking their meds, this is more likely to be a real rebound.

This can be a reason to change treatment.

How Can Drugs "Fail" When I Feel Fine?

"Viral failure" relates to results from a blood test but not to how well you feel.

If you stay on a failing treatment, your CD4 count will start to drop.

This might not be for several months but it will happen.

A lower CD4 count increases the risk of new or progressing illness. This is called "clinical failure." See Figure 3.

Figure 3. From Rebound to Symptoms

Figure 3. From Rebound to Symptoms
  1. Viral load rebounds. If you stay on the same meds, viral load will continue to rise.
  2. Your CD4 count will go down over time.
  3. As your CD4 count drops the risk of symptoms increases.

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This article was provided by HIV i-Base. Visit HIV i-Base's website to find out more about their activities, publications and services.


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