Unable to reach undetectable


I started hiv meds in March 2009 with a viral load of approx 120000 and cd4 230. My doctor suggested Truvada and Viramune. I took my meds religiously and initially they seemed to be working, with my viral load dropping to 68 and cd4 in the 450 range. However by month 14 I still hadn't reached undetectable, with my vl hovering around 200. My doc decided to change my regime to darunivir (800mg), ritonivir (100mg) and maraviroc (300mg). I have been on this combination for 2 months now and although my cd4 has risen to around 600, percentage at 35%, my viral load is staying at the 200 mark. My doctor has now added 3TC to my combination to see if this will help me get to undetectable. He says that some people are just slower than others to get there. Do you think that adding this drug is necessary and will increase my chance of achieving undetectable? I'm worried about adding another potent drug to my regime if its not going to help! I'd also appreciate your thoughts on any other combinations which I may consider. Is it possible that I may never reach undetectable even though I am 100% compliant? Sorry for the long winded questions. I would really value your opinion.


A worried patient in the UK


Dear worried in the UK,

Occasionally we see people who have stubborn viral loads to fully suppress. The biggest worry that we as clinicians have is that the person may be missing doses. Since you know best that is not the issue here.

It is true that, especially when starting out with a high viral load (over 100,000) it may take time to get to undtectable, but generally by 16 weeks (and certainly 24 weeks) we would expect an undetectable level. In that case "intensifying" treatment is a good idea. So the switch to a different modality of treatment is important. A "Boosted protease inhibitor" strategy (which you have tried) is very reasonable. I would check on teh dose of maraviroc, which should be 150 mg twice daily with a ritonavir containing regimen.

Since there has been no change in the viral load there may be a couple of things to consider:

  1. Check on the process that the viral loads are being sent...specimen handling can cause false results sometimes. Sometimes going to a reference lab to have the bloods drawn may be tried.
  2. Have your docs look for a cause of ongoing immune activation (or inflammation) in the body. This may be due to chronic relapsing infections such as herpes or HHV-8, etc.
  3. Further attempt at intensification may help. Even though you are taking 3 meds, only 2 are doing the killing and this is an unorthodox combo, especially if the maraviroc is once a day. Adding a nucleoside such as truvada and/or changing the darunavir/ritonavir to twice daily (even for a short time) may help answer once and for all if intensification will help.

Best, Joe