Atripla - A miracle?

[buffaloboy]

I started on Atripla (my first regime) in October and simply couldn't handle the central nervous system side effects so stopped after 18 days. I took Truvada for 10 days after to avoid drug resistance issues, on the advice of my doctor. Around 11 days after stopping all medication I had a viral load blood draw and the result came today which had dropped to 2,160. Now, my last viral load taken at the beginning of October was around 600,000.

The thing is, my doctor said because my CD4 count was so low (84) and my viral load so high, it would be, in his own words, ' ...a long haul back to healthy numbers', but the very brief time I spent on medication would appear to refute this.

We won't be looking at alternative regimes until after Christmas now, so the other thing I'm wondering is, if the viral load can plummet so dramatically in a very short space on medication, can it also jump sky-high again in the space of two or three weeks when you stop?

And lastly, does a good virologic response on one regime automatically mean this will be the case on all others you switch to, or is that wholly dependent on the drugs?

Any thoughts?

[Inchlingblue]

We won't be looking at alternative regimes until after Christmas now, so the other thing I'm wondering is, if the viral load can plummet so dramatically in a very short space on medication, can it also jump sky-high again in the space of two or three weeks when you stop?

And lastly, does a good virologic response on one regime automatically mean this will be the case on all others you switch to, or is that wholly dependent on the drugs?

Any thoughts?

Viral loads can indeed jump "sky-high" again in the absence of meds. Of course, this can vary among individuals as far as how fast and how high but as a general rule, yes, they can go back to very high numbers, especially with low CD4s. You should keep in mind that in the absence of meds HIV copies itself in our bodies billions of times a day. Another factor would be length of time one has had HIV. If you were recently infected then you might not experience a huge rebound.

When you are looking at blood test results, the HIV viral load is whatever number "per milliliter of blood." And the CD4 count is "per cubic milliliter of blood." So if you had a 600,000 viral load that would be "per milliliter of blood," not 600,000 total.

As far as the great virological response you experienced, all of the top-of-the-line meds work extremely well, assuming there is no resistance. Some work faster than others. Sustiva, which is in Atripla works pretty fast and Isentress has been shown to work just as fast, maybe even faster. A recent study of a new integrase inhibitor that is not yet approved showed the fastest virological response of any compound/drug so far.

I think the level of one's response is most likely a combination of the individual's immune system and genetic makeup, length of time of infection and the level of strength of certain drugs over others. If you go back on meds you should respond very well. You were well on your way to becoming undetectable very quickly.

I don't get why you are waiting until after X-mas to even be looking at alternative combos? If your CD4s are still below 200 it doesn't sound like a good idea.

[buffaloboy]

''I don't get why you are waiting until after X-mas to even be looking at alternative combos? If your CD4s are still below 200 it doesn't sound like a good idea.''

The reason we're waiting until after Christmas is because my doctor ordered nine different blood tests and the results have only just come back. My next appointment with him isn't until the 11th December and then, of course, the clinic will be pretty much be on closedown a couple of weeks after that for the holidays and won't return to regular opening hours until January 4th.

What I don't like is the idea that I might experience side effects when embarking on the new regime and not be able to speak to, or see, anyone at the clinic. I had such a bad reaction on Atripla and definitely don't want to feel as if I have to suffer in silence on any new drugs too.

So, that's why we are waiting until the new year.

[Inchlingblue]

You shouldn't let the Atripla experience give you concerns over other drugs causing immediate unbearable side effects. The one drug most likely to cause these kinds of side effects is Atripla, because of Sustiva. All of the other top-of-the-line, latest HIV drugs are very bearable with minimal if any immediate side effects.

Are you on antibiotic prophylaxis so you can avoid OIs as much as possible?

[Miss Philicia]

I agree that you should not wait until after Christmas.  Indeed, I might even call it irresponsible and negligent on the part of the doctor not to counsel you strongly against this decision.

[mecch]

Hmm why are you waiting?

As to the viral load impact of today's haart, ask your ID to draw you the curve - to explain about log drops. Its very quick and easy to knock high viral loads down to the low thousands, as you have seen. The viral load drops by logs.  
Afterwhich it can take its own time to get to undectable.
I think the long haul your ID refers to is rebuilding your CD4.
In any event, good luck with the next try and
I were you, I wouldn't be waiting months...
In the meantime, if you do, you need to see the doc anyway to get preventive drugs for other infections.

[buffaloboy]

''You shouldn't let the Atripla experience give you concerns over other drugs causing immediate unbearable side effects. The one drug most likely to cause these kinds of side effects is Atripla, because of Sustiva. All of the other top-of-the-line, latest HIV drugs are very bearable with minimal if any immediate side effects.

Are you on antibiotic prophylaxis so you can avoid OIs as much as possible?''

I've read other discussions on here about people having issues when starting Sustiva-sparing regimes, so I don't want to rely on the idea that there probably won't be any immediate side effects. Nevirapine can cause Stephen Johnson Syndrome shortly after starting, so if started to develop a rash, I would certainly want someone in my clinic to investigate immediately, if only to put my mind at rest.

I'm currently taking Bactrim as a prophlyactic for PCP.

''I  agree that you should not wait until after Christmas.  Indeed, I might even call it irresponsible and negligent on the part of the doctor not to counsel you strongly against this decision.''

The new year is only 5 weeks away so I'm OK about waiting until then to consider the alternatives and start new treatment, although I accept that other people might not feel comfortable doing that themselves.  I'd rather try and get the next one right to save having to stop and start all again.

[buffaloboy]

''Hmm why are you waiting?

As to the viral load impact of today's haart, ask your ID to draw you the curve - to explain about log drops. Its very quick and easy to knock high viral loads down to the low thousands, as you have seen. The viral load drops by logs. 
Afterwhich it can take its own time to get to undectable.
I think the long haul your ID refers to is rebuilding your CD4.
In any event, good luck with the next try and
I were you, I wouldn't be waiting months...
In the meantime, if you do, you need to see the doc anyway to get preventive drugs for other infections.''

Ah, undectectable. So that can be the tricky bit, right? That sort of makes sense.

I don't intend to wait 'months',  just until January. However, it's worth noting that at my clinic the lead time for an appointment with my doctor is around 3-4 weeks. So after I've seen him on the 11th, the earliest I'd be able meet with him again would be right at the start of January.

By the way, what's an ID? We don't use that term in the UK, other than to mean 'identity', as in ID card.

[Ann]

ID is short for Infectious Disease doctor. You do hear it occasionally here in the UK, but probably not as often as in the States.

The tricky bit shouldn't be becoming undetectable, and going by how quickly your VL came down on Atripla, you'll probably be undetectable within a few months, at the very most, on another combo. The tricky bit is more likely, for you, to be getting your CD4 count back up to more normal levels. Sometimes people struggle for years to get over 200 when they started meds with a low CD4. Good luck in the New Year with your next combo. I can't believe it's almost 2010 already!

Ann

[buffaloboy]

The tricky bit shouldn't be becoming undetectable, and going by how quickly your VL came down on Atripla, you'll probably be undetectable within a few months, at the very most, on another combo. The tricky bit is more likely, for you, to be getting your CD4 count back up to more normal levels. Sometimes people struggle for years to get over 200 when they started meds with a low CD4.

When I last saw my doctor, he said his main priority was getting my viral load to undectable levels. He said that  as long as I was on medication he would be happy to not take  my CD4 count for a couple of years, although he acknowledged that patients are interested in knowing what it is. I did find this a little strange, as when you're not on treatment, the doctors and nurses do little else other than obsess about a falling CD4 count, and warn you of the risks you are at once you dip below a certain threshold.

[buffaloboy]

''ID is short for Infectious Disease doctor. You do hear it occasionally here in the UK, but probably not as often as in the States. ''

I don't like the terminology of 'infectious disease doctor', as it has stigmatising ring to it. I'm glad it's not in common use in the UK.

[Ann]

When I last saw my doctor, he said his main priority was getting my viral load to undectable levels. He said that  as long as I was on medication he would be happy to not take  my CD4 count for a couple of years, although he acknowledged that patients are interested in knowing what it is. I did find this a little strange, as when you're not on treatment, the doctors and nurses do little else other than obsess about a falling CD4 count, and warn you of the risks you are at once you dip below a certain threshold.

It's true that when on treatment, the most important thing is that your VL remains undetectable. However, your doctor saying he'd be happy to not look at your CD4s doesn't sound right, with your CD4s being under 200. You'll be able to go off the Bactrim when your CD4s go over (and stay over) 200, so that just doesn't make sense, unless he's happy (and you're happy) to stay on Bactrim even when you might not need it. If it were me, I'd be questioning him about this. Don't ever be afraid to question your doctor. I'm not!

''ID is short for Infectious Disease doctor. You do hear it occasionally here in the UK, but probably not as often as in the States. ''

I don't like the terminology of 'infectious disease doctor', as it has stigmatising ring to it. I'm glad it's not in common use in the UK.

Yeah, I'm not too fond of the term either. I usually call my hiv doc just that - my hiv doc, just to differentiate between him and my GP. I also refer to my hiv doc as the Wizard of Poz, because I think he's wonderful. The registrars I end up seeing sometimes (my clinic is at the Liverpool Royal, which is a teaching hospital, so I get to be a teaching prop quite often) leave a lot to be desired and it's usually them that I question, question, question! Some of them are a little afraid of me, I think.

Ann

[buffaloboy]

It's true that when on treatment, the most important thing is that your VL remains undetectable. However, your doctor saying he'd be happy to not look at your CD4s doesn't sound right, with your CD4s being under 200. You'll be able to go off the Bactrim when your CD4s go over (and stay over) 200, so that just doesn't make sense, unless he's happy (and you're happy) to stay on Bactrim even when you might not need it. If it were me, I'd be questioning him about this. Don't ever be afraid to question your doctor. I'm not!

Yeah, I'm not too fond of the term either. I usually call my hiv doc just that - my hiv doc, just to differentiate between him and my GP. I also refer to my hiv doc as the Wizard of Poz, because I think he's wonderful. The registrars I end up seeing sometimes (my clinic is at the Liverpool Royal, which is a teaching hospital, so I get to be a teaching prop quite often) leave a lot to be desired and it's usually them that I question, question, question! Some of them are a little afraid of me, I think.

Ann

At my clinic, they have a walk-in service for regular blood work, so even if my doctor didn't request a test, then I'd still be able to find out what my CD4 was.

But I'm all for questioning clinic staff, even if that means appearing intimidating. Given the complex nature of both HIV and the treatment, they should expect that (some) patients will want as full an explanation as it's possible to give, and it's their duty - not an optional extra - to be able to deliver on that.

[Ann]

they should expect that (some) patients will want as full an explanation as it's possible to give, and it's their duty - not an optional extra - to be able to deliver on that.

Absolutely. And it 's more than a little disconcerting when, in the course of asking questions, I realise that the registrar I'm speaking to knows less about hiv than I do. Sometimes I start asking questions just for devilment. If I've got something specific I want or need to talk about, I request to see my main doc, but if I'm just there to get my latest labs, I'll amuse myself with a little sport with whoever the latest registrar happens to be. Some of them don't even look old enough to have gone through medical school, and they're the ones who usually get that caught-in-the-headlights look in their eyes. My regular doc thinks it's funny, and he also thinks I'm doing them a service by pointing out their lack of knowledge in a round-about way.

Ann

[82boxer]

Hey buffaloboy!

My specialist offered:

Atripla once a day
-OR-
atazanavir (300mg) + ritonavir (100mg, potentiates and increases bioavailability for atazanavir) + Truvada (300mg tenofovir/200mg emtricitibine) once a day.  

I chose the atazanavir combo since she said it is a preferred first line treatment that is very well tolerated, well documented and well studied - she was SO right.  I also tend to consider newer drugs with more weight as well (atazanavir 2003 vs. Atripla's efavirenz 1998).  Since I am an RN student, I didn't want any CNS baggage associated with efavirenz.

My only side-effect is that once in a blue moon I get slight jaundice in my eyes that I find only presents itself when I am dehydrated.  It was also indicated to me that to correct more serious jaundice, they will remove the ritonavir from that combonation and increase the atazanavir to 400mg, after some tests of course.

http://forums.poz.com/index.php?topic=22193.0 is a conversation about the combo.

Good luck!  

[Poz 2008]

Greetings Buffaloboy!

I just wanted to add that I, too, had horrible side effects from Atripla.  I only took two pills and stopped.  The plan was to treat early as I had seroconverted a month before I took the Atripla. However, because I was so traumatized by Atripla, I chose to wait on treatment (my CD4 was barely above 500 at the time).

A year and a half passed, and my numbers have slowly dropped to where I have decided to try meds again. Three days ago, I started Isentress and Truvada.  I can happily tell you that I am feeling no side effects from this regimen whatsoever!  So, don't be discouraged by your Atripla experience. There are other regimens out there that are VERY tolerable... totally unlike the Atripla experience.  Start treatment as soon as you can.

Good luck!