Newly diagnosed and viral load too low for genotyping

Question

I was infected with HIV-1 on 9/15/2009 and diagnosed on 10/6/2009. The labs are as follows: 10/15/2009 CD4 - 361, VL - 532, 11/05/2009 CD4 - 446, VL - 283. In both rounds of labs, they could not do any drug resistance or tropism testing because the viral load was too low. After reviewing a lot of primary studies, I want to start taking the meds as soon as possible. What are your thoughts on which meds to choose and when to start.

Answer

Hello and thank you for your post.

I'd generally agree with you regarding when to start HIV treatment. It's good news (in a way) that your viral load is so low- this means that you have a better prognosis overall and don't really have any risks related to the potency of your HIV medications.

Unfortunately, this low viral load also makes it technically very difficult to obtain the HIV resistance test that is recommended in the US and Europe. Therefore, recognizing that non-nucleoside resistance is the more commonly transmitted resistance, avoidance of a non-nuke regimen is usually done (at least by me) in this circumstance; to avoid prescribing an initial regimen that your virus might already be resistant to.

Hence, we'd usually start with a two nuke combination-- usually Truvada (tenofovir+FTC) or Epzicom (abacavir+3TC) with a boosted protease inhibitor (alphabetically, atazanavir, darunavir, fosamprenavir or lopinavir). This is particularly the case since ritonavir-boosted PIs are very potent, even in the face of most types of baseline resistance.

I hope this helps.

BY