Speaking of being "detectable"

[RAB]

Just got a call from my doctor.  He wants to see me on Wed. to do some additional testing.

My latest VL came back at 110

No big deal right?

Problem is this is the 3rd time it's happened.

First VL came back @ 60
Follow up test <48

Second VL came back @ 70
Follow up test <48

This is all in the last 9 months.  Started when he switched from dual PI (Kaletra Invirase) to boosted Prezista

Don't know what additional tests he wants to do.  Not high enough to do a resistance test.

Other meds are Viread/Epivir/Isentress.

Newt or anyone else got any thoughts?

RAB

[newt]

hmmm.....difficult.

Inclined to say these days it don't matter, "undetectable" is an outdated concept. The recent generation of tests have got very sensitive. My clinic will retest on more than 40 but not be concerned if under 200.

That the restests were under 48 (presumably the limit of the test) is encouraging. Very much. Suggests temporary, accidental result. In truth all viral load levels are a saw-tooth of ups and downs, it's just test haven't been able to capture this til now.

You might ask if they have changed to a more up-to-date (= more sensitive) test at the lab recently. If so, will need to reset/decide your parameters for "successs" (probably higher, around 200 copies).

Consistently under 50 yes, the target, if the next test rises over 200, concerned be (but not too much) and get a resistance test anyhow...if it's an important one will show on about 200-500 copies. Prezista....unlikely to be less effective, and resistance busting, but you never know eh? 100 or so copies, I, personally, wouldn't be sweating.

- matt

(soz, useless and demotivating this post I am thinking)

- matt

[Inchlingblue]

He might want to do a branch DNA test.

if you search on here for "branch DNA" or "bDNA" you'll find threads in which it's been discussed in relation to its use as a follow-up when previous tests came back detectable.

[RAB]

Thanks Newt for the calming thoughtful response.  Yeah the test they use doesn't go below 48.  And it's good to hear that it probably isn't the Prezista switch.  I'm very concerned but certainly not in a panic----YET!

Inching, you may be right about the DNAbranch, I've read about it earlier, but haven't really paid that much attention recently.

I had nearly a 15 year track record of being undect. (with the exception of a 9 month treatment break for metabolic toxicity [thank you full strength Norvir]), this from a man with 27 mutations (thank you mono-therapy).

I'll just wait to see what is what on Wed.

Thanks again to both of you.

RAB

[Lou-ah-vull]

Hoping this is nothing other than the so-called "blip."  I can imagine how disturbing it is though.  I know you will let us know.

Gary

[tednlou2]

http://www.hopkins-hivguide.org/q_a/patient/recent_questions/atripla_regimen_failure...or_temporary_blip_.html?contentInstanceId=542500&siteId=7151

[Inchlingblue]

Do you know if the original tests were done using TaqMan RNA Assay?

This is interesting:

http://blogs.jwatch.org/hiv-id-observations/index.php/taqman-hiv-rna-assay-be-careful-what-you-wish-for/2009/03/04/

[AlanBama]

I hope it is nothing more than a 'blip'....but I definitely understand your concern.

I have had two of these 'blips' in recent months, the latest on Jan 24th.   But the "re-test" showed <40.

Our clinic is using the more sensitive test Newt is talking about....they tell us there has been a lit of "blipping" lately....

Sounds like a new dance....the BLIP   

[RAB]

Thanks Inch for the info.  I have no idea which test they are using but I'll ask tomorrow.

RAB

[elf]

Yeah, TaqMan is a more sophisticated test. 

[newt]

Good lowdown on TaqMan from Paul E Sax, MD, Clinical Director of the HIV Program and Division of Infectious Diseases at Brigham and Women’s Hospital and Associate Professor of Medicine at Harvard Medical School:

http://blogs.jwatch.org/hiv-id-observations/index.php/taqman-hiv-rna-assay-be-careful-what-you-wish-for/2009/03/04/

- matt

[thunter34]

Sounds like a new dance....the BLIP   

And TaqMan sounds like a video game.

[Assurbanipal]

The 2011 revised US treatment guidelines spend a fair amount of time on this question.  I wish they had been out a couple of years ago when this happened to me.  

Basically the guidelines now define successful treatment as getting to a viral load under 48 (no change there), but they redefine what constitutes failure to say that it means repeated viral loads above 200 (used to say repeated detectable viral load).

The page numbered 68 (which is page 76 of the pdf file) lays it out pretty well  http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf

"

Virologic suppression: A confirmed HIV RNA level below the limit of assay detection (e.g., <48 copies/mL).

Virologic failure: The inability to achieve or maintain suppression of viral replication (to an HIV RNA level <200 copies/mL)."

So basically the new US guidelines say not to worry as long as it stays under 200 on repeated tests.

Note, getting the branch DNA test does not give any additional information of value if your viral load is under 150 or so, since that more or less automatically translates to an undetectable level on the bDNA test (they read different quantities of virus and have different standards at which they determine an undetectable viral load)

Best

A

[eric48]

50 is the cut-off, that's when HIV goes to sleep (<< references available).  Who cares about 20 copies/mL or 2?
- matt[/font]

In a recent meeting of our local researchers one of our prominent expert presented a list of 'current topics'

the question "Is there any benefit in lowering the detection limit to 5 in clinical practice?" was among the list. (no answer was provided)

Apparently some people seem to care...It is an open question. Not a closed issue.

Now that research facilities have access to detection limits down to 1 IN BLOOD, they are looking at the relevance of the going that low (in research as well as in clinical practice).

The background is that not all the compartments of the body are equally protected by meds.

A recent study showed that Nevirapine users are significantly more likely to achieve 1 copy /mL than EFV users and suggested that this is because NVP has a better penetration into CNS than EFV
http://www.ncbi.nlm.nih.gov/pubmed/21157295

A recent article was citing a case of a UD patient who had developed resistance to Raltegravir in his CNS
http://www.ncbi.nlm.nih.gov/pubmed/21297097
(thus raising concern that meds with limited penetration into some parts of the body would thus allow VL over 50 in those parts while VL is maintained < 50 in peripheral blood)

If the virus is suppressed in 100% of the body then HIV goes to sleep. Most probably correct (even on the long term)

But what if, on the long run, the virus is suppressed in 90 % and is somehow freely replicating in say 10 % of the body mass. Resistance could then develop in that compartment. Whether this is clinically significant or not is, IMHO, an open question.

IF tests down to 5 or 1 in peripheral blood can provide a picture of how well the meds are penetrating into other areas than peripheral blood, then they may be clinically relevant and provide a predictor for how long a given regimen can be sustained.

Citing conclusion of :
http://www.ncbi.nlm.nih.gov/pubmed/21157295

----------------

The clinical relevance of having a viral load below 1 copy/ml has now to be studied for example on systemic inflammatory or immune activation markers.

----------------

So " Who cares about 20 copies/mL or 2?"

Well...

Why not wait until this matter is explored further before dismissing the potential interest of ultrasensitive assays.

Just some thoughts

Eric



 

[eric48]

side note to :

http://www.ncbi.nlm.nih.gov/pubmed/21157295

you may notice that the percentage of patients with HIV-1 RNA below 1 copy/ml is in both cases > 50 %, which, i think, is quite impressive...

Eric

[elf]

But, as mentioned before, residual viremia comes from reservoirs (bone marrow, lymphatic tissue) and does not mean that the virus is replicating in CD4 cells and monocytes in blood.

So, that means that the body is clearing itself from the virus.

Our goal is to eliminate that virus from reservoirs, so 0 copies of HIV in blood would mean the reservoirs are not being cleared from the virus.

Any news on Prostatin?
http://en.wikipedia.org/wiki/Prostratin

Chasing HIV from Its Hiding Place
http://www.jeanne-erdmann.com/wp-content/uploads/2010/09/HIV-Story.pdf

[RAB]

Well here's what doctor thinks regarding my recent spurt of VL >50.

It's either because:  He just doesn't know if it's one or the other.

The type of test kit they use to check VL was changed at the same time as my first VL of 60, meaning it's more sensitive.  However regardless of what kit the goal is still to get under 50.

My switch from a dual PI regimen to the boosted Prezista may also be a factor.  He says they have no data indicating that a dual PI is better than a single PI, but admits it could be possible in my case the dual PI was a more durable regimen.

He reran the VL and did a tropismDNA test to see if Selzentry would be an option.  He also agreed to let me switch back to the dual PI to see if that helps.

When he walked into the room he said:  "I expected to see that look on your face."  I guess my concern was showing.  But he reassured me that even at 110 I'm still "undetectable" for all practical purposes.
Essentially the same thing Newt posted.

He didn't think the branchDNA would tell us anything useful (though for the life of me I can't remember why  he said that).

So we'll just wait and see.

Thanks to everyone for your thoughts and info.

I'll report back when I know more.

RAB

[newt]

I am interested why you needed to change, other that Kaletra Invirase being potentially yucky cholesterol wise and entailling a lot of toilet paper.

You can do Prezista with Reyataz if need be, like it must be PIs.

Also the 600mg 2 x day Prezista has better pharmokinetics than the 1 x day 800mg dosing, this might be enough to shave off the last few virons (but, hey, you's gonna say your doc already went for this, right? hmmm...).

- matt

[RAB]

I am interested why you needed to change, other that Kaletra Invirase being potentially yucky cholesterol wise and entailling a lot of toilet paper.

You can do Prezista with Reyataz if need be, like it must be PIs.

Also the 600mg 2 x day Prezista has better pharmokinetics than the 1 x day 800mg dosing, this might be enough to shave off the last few virons (but, hey, you's gonna say your doc already went for this, right? hmmm...).

- matt

I'm currently taking the 600 mg 2X day of Prezista, so that won't make any difference.

You make a valid point regarding the side problems of Kaletra and Invirase.  He (doc) went for it because I pushed hard, in my mind because it had worked so well for so long, I felt I at least needed to give it a try.  Can Invirase be added to Prezista w/fewer side problems?  Maybe that's the way to go if so. 

Thanks buddy.

RAB

[newt]

Can Invirase be added to Prezista w/fewer side problems?

No it can't, nor can it be added to Kaletra. Prezista can be added to raltegravir (Isentress), nevirapine (Viramune) and etravirine (Intelence) ... and perhaps maraviroc (Selzentry) if you have perfect kidney function.

- matt

[Jody]

To my dearest RAB, when I first went on Reyataz, Norvir and Truvada I also had a blip, then I switched the Reyataz for Prezista and have not since been detectable by the standards currently used.  Anyway I think your regimen is so much better than that awful Fuzeon you so dreaded.  Best of luck going forward getting what is best for you, both for tolerance and for staying healthy, you are one of the best of people.

Jody

[Lou-ah-vull]

Ditto...that you are one of the best of people.  Keeping my fingers crossed that this will all be water under the bridge for you.  It is very kind of you to share this with others who will clearly benefit from your experience.

See ya in Seattle!

Gary