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Author Topic: Adherence and Virological Rebound  (Read 3081 times)

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Offline MBK

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  • Posts: 19
Adherence and Virological Rebound
« on: February 01, 2010, 01:14:26 AM »
Hey Everyone:

I have been on ARV for about 9 months now. I have been searching for some data regarding ARV efficacy assuming 100% adherence and haven't been able to find anything conclusive. Can anyone share with me their experience or any studies that they may have read. Particularly, I am interested in finding out:

- Has anyone who has been 100% (or near 100%) adherent ever experience a virological rebound after they have had reach undetectable levels?
- What medication were you on?
- Was the treatment failure due to a mutation in the virus that was not caught or due to other reasons?

I guess the reason I am asking is whether or not I can expect full and sustained suppression for... well basically ever... as long as I am 100% adherent (assuming no underlying mutation)?

Thanks!

Offline MBK

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Adherence and Virological Rebound
« Reply #1 on: February 01, 2010, 01:36:30 AM »
Hey Everyone:

I have been on ARV for about 9 months now. I have been searching for some data regarding ARV efficacy assuming 100% adherence and haven't been able to find anything conclusive. Can anyone share with me their experience or any studies that they may have read. Particularly, I am interested in finding out:

- Has anyone who has been 100% (or near 100%) adherent ever experience a virological rebound after they have had reach undetectable levels?
- What medication were you on?
- Was the treatment failure due to a mutation in the virus that was not caught or due to other reasons?

I guess the reason I am asking is whether or not I can expect full and sustained suppression for... well basically ever... as long as I am 100% adherent (assuming no underlying mutation)?

Thanks!

N.B. I posted this in the Living with HIV forum. Apologies for the double post.

Offline randym431

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Re: Adherence and Virological Rebound
« Reply #2 on: February 01, 2010, 04:02:06 AM »
Good question. Adherence seems to be the #1 concern of my doctor. First thing he asks me when I see him, "mis any dosages?". Also, once he muttered to himself in surprise, "oh.. youre still on the same combo". So I gathered adherence must be the main problem issue with his other patients. Myself, I've been on the same meds since first starting in 2005, never missing, and doing very well.

Offline veritas

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Re: Adherence and Virological Rebound
« Reply #3 on: February 01, 2010, 06:08:30 AM »

MBK,

The very short answer is =Yes, it is possible for a number of reasons, however, not as likely as someone who is reckless with adherance. You asked for some studies:

http://www.ias2007.org/pag/PosterExhibition.aspx?presType=PE&day=25&Track=All&absCat=Immunological+and+virological+outcome+of+ART

Click on "ABSTRACT" on the left side of the page, if you find any of the titles intriguing for the complete explanation.

Here's another easy to read discussion on adherence:


http://www.medscape.com/viewarticle/528181_4
You did not post your medications, so I don't know what medications your on.

Advice: Stay 100% adherent

v

Offline veritas

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Re: Adherence and Virological Rebound
« Reply #4 on: February 01, 2010, 06:11:46 AM »

Answered your post in the other forum. Perhaps both threads should be combined. Moderators?

Offline Ann

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Re: Adherence and Virological Rebound
« Reply #5 on: February 01, 2010, 07:07:59 AM »
M, I moved your identical thread in Living and merged it with this one in Treatment, which is the more appropriate forum for your question.

To post the same (or very similar) thread in more than one forum is considered to be spamming and is not good forum etiquette. No harm done, but please remember this in future. It's also for your own benefit as you will have all the information in one place. :)

Ann
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline tommy246

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Re: Adherence and Virological Rebound
« Reply #6 on: February 01, 2010, 08:13:06 AM »
Hey Everyone:

I have been on ARV for about 9 months now. I have been searching for some data regarding ARV efficacy assuming 100% adherence and haven't been able to find anything conclusive. Can anyone share with me their experience or any studies that they may have read. Particularly, I am interested in finding out:

- Has anyone who has been 100% (or near 100%) adherent ever experience a virological rebound after they have had reach undetectable levels?
- What medication were you on?
- Was the treatment failure due to a mutation in the virus that was not caught or due to other reasons?

I guess the reason I am asking is whether or not I can expect full and sustained suppression for... well basically ever... as long as I am 100% adherent (assuming no underlying mutation)?

Thanks!

Hi im only on atripla for two months now but i asked my hiv specialist with over twenty years experience at the local hospital a similar question. Basically he said that if we are 100 % adherent with modern meds which keep us undetectable then the virus cant mutate so the regimen should work long term causing no reason to change meds.
jan 06 neg
dec 08 pos cd4 505 ,16%, 1,500vl
april 09 cd4 635 ,16%,60,000
july 09 ,cd4 545,17%,80,000
aug 09,hosptal 18days pneumonia cd190,225,000,15%
1 week later cd4 415 20%
nov 09 cd4 591 ,vl 59,000,14%,started atripla
dec 09  cd4 787, vl 266, 16%
march 2010  cd4 720 vl non detectable -20  20%
june 2010  cd4  680, 21%, ND

Offline Inchlingblue

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Re: Adherence and Virological Rebound
« Reply #7 on: February 01, 2010, 10:15:20 AM »
Here's a thread that might be helpful:

http://forums.poz.com/index.php?topic=28272.0

Offline MBK

  • Member
  • Posts: 19
Re: Adherence and Virological Rebound
« Reply #8 on: February 01, 2010, 01:21:51 PM »
MBK,

The very short answer is =Yes, it is possible for a number of reasons, however, not as likely as someone who is reckless with adherance. You asked for some studies:

http://www.ias2007.org/pag/PosterExhibition.aspx?presType=PE&day=25&Track=All&absCat=Immunological+and+virological+outcome+of+ART

Click on "ABSTRACT" on the left side of the page, if you find any of the titles intriguing for the complete explanation.

Here's another easy to read discussion on adherence:


http://www.medscape.com/viewarticle/528181_4
You did not post your medications, so I don't know what medications your on.

Advice: Stay 100% adherent

v


Thanks Veritas. I had read all these in the past. None of them deal specifically with the following scenario:

You are on your drugs. 100% adherent. Undetectable. Remain 100% adherent. No baseline mutations. Can you experience virological rebount (beyond just a blip, meaning two consecutive tests) or virological failure.

All studies I have seen use self-reporting (which is typically very much under-reported). Maybe a meta-study? I figured I would ask on these boards since people are more likely to be straightforward about this.

I plan to be 100% adherent ;-)

Prezista 800mg + Norvir 100mg + Truvada 300mg/400mg once a day.

Offline MBK

  • Member
  • Posts: 19
Re: Adherence and Virological Rebound
« Reply #9 on: February 01, 2010, 01:24:00 PM »
M, I moved your identical thread in Living and merged it with this one in Treatment, which is the more appropriate forum for your question.

To post the same (or very similar) thread in more than one forum is considered to be spamming and is not good forum etiquette. No harm done, but please remember this in future. It's also for your own benefit as you will have all the information in one place. :)

Ann

Hi Ann! Thank you so much for merging those. I had never ventured beyond the first forum then when I noticed that there was another more appropriate place to post I put it there with an apology for the double post. I just wasn't sure how to delete the first one ;-). Thank you very much for doing that!

Offline Ann

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  • It just is, OK?
    • Num is sum qui mentiar tibi?
Re: Adherence and Virological Rebound
« Reply #10 on: February 01, 2010, 01:45:44 PM »
Hi Ann! Thank you so much for merging those. I had never ventured beyond the first forum then when I noticed that there was another more appropriate place to post I put it there with an apology for the double post. I just wasn't sure how to delete the first one ;-). Thank you very much for doing that!

No problem, M. If you make a mistake like that in future, let me know via PM or make mention in the thread and I'll move it for you, rather than you creating a new thread. ;)

Ann
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline MBK

  • Member
  • Posts: 19
Re: Adherence and Virological Rebound
« Reply #11 on: February 01, 2010, 01:48:55 PM »
Thanks Inchlingblue!

This is the best study I have found so far http://www.natap.org/2009/IAS/IAS_92.htm

There is no doubt in my mind that the longer your are suppressed, the more likely you are to continue being suppressed. I also believe the choice of drug combination at initiation of therapy is important. Even though I chose a boosted PI, I think NNRTIs are a better choice (I don't have solid data to back this up but I am willing to bet that the faster the VL is reduced the less likely virological rebound/failure is). If Glaxo's GSK1349572 experimental integrase inhibitor was available I would have added it to my regimen in a heartbeat! 2.5log vl decrease on average after 11 days on the 50mg dosage).

Anyway, thanks guys, please keep it coming!

Offline Inchlingblue

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Re: Adherence and Virological Rebound
« Reply #12 on: February 01, 2010, 02:48:31 PM »
Isentress (and Kaltera) has been shown to promote rapid viral decline:

http://www.hivplusmag.com/NewsStory.asp?id=20412&sd=04/29/2009

Anecdotally:

I went UD in less than 2 weeks, test was done after 2 weeks, was probably UD much sooner (I had a low viral load, 9K, but still).

This member, on Isentress/Truvada went UD in 3 weeks starting with a VL of 150K:

http://forums.poz.com/index.php?topic=30273.0

Offline Assurbanipal

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  • Posts: 2,173
  • Taking a forums break, still see PM's
Re: Adherence and Virological Rebound
« Reply #13 on: February 01, 2010, 04:22:52 PM »
...- Has anyone who has been 100% (or near 100%) adherent ever experience a virological rebound after they have had reach undetectable levels?
- What medication were you on?
- Was the treatment failure due to a mutation in the virus that was not caught or due to other reasons?

I guess the reason I am asking is whether or not I can expect full and sustained suppression for... well basically ever... as long as I am 100% adherent (assuming no underlying mutation)?

Thanks!

Yes.  I was undetectable for 9 - 12 months and then had a rebound to a very low level (VL 100-130).  Adherence was over 99% and 100% during the period immediately preceding becoming detectable again. 

Initially I thought it was a blip, but it persisted over a period of months.  The viral load was too low to determine whether there was resistance and there is no consensus in the US treatment guidelines as to whether or not, at that low a level, to change medications.  Due to other issues (osteoporosis and lipids) I decided to change medications anyway and have since been undetectable again.

More details (and with EXTRA BONUS contemporaneous agonizing  ;) ) here.  http://forums.poz.com/index.php?topic=26412.0

My case was rare to my doctor, but apparently not wildly out of the mainstream.  Certainly the US treatment guidelines indicate that not everyone will attain permanent undetectable status, even with 100% adherence. 

As to what you should expect ---  I think you will do much better if you expect success, which also appears to be the most likely outcome.  And why borrow trouble?  Control that thing that which you can ... adherence ... and deal with any uncontrollable problems only if they arise. 

Be well
A
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline MBK

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Re: Adherence and Virological Rebound
« Reply #14 on: February 01, 2010, 05:32:29 PM »
Absolutely. 100% is my goal.

I think clinically speaking the outcome of VL < 50 or VL <400 is relatively equivalent. The truth is that viremia is never fully suppressed so a VL of 130 is pretty much as good as a VL < 50 in my book. You could have very well be hovering at 47 (right below the limit of detection) so going from there to 70 or 130...  I'd still say that the drugs were working properly. I would probably go as far as saying that anything below 500 stable is great (that mimics elite controllers).

Were you or your provider concerned at all with a viral escape when that happened?

Offline newt

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Re: Adherence and Virological Rebound
« Reply #15 on: February 01, 2010, 06:02:23 PM »
Quote
You are on your drugs. 100% adherent. Undetectable. Remain 100% adherent. No baseline mutations. Can you experience virological rebound (beyond just a blip, meaning two consecutive tests) or virological failure.
Really, only if you don't absorb the drugs properly. This is unusual.

If you reach undetectable, like less than 50 copies, and stay there, the scenario you paint is unlikely if you have good adherence.

With the latest (Roche) tests, under 200 consistently is basically the same as under 50 on older tests (please don't ask why)

Viral rebound (therefore possible resistance) will at least double your viral load from one test to another then do the same again, or stay well above 200.

Blips, ie one odd high result, are relatively common

-matt
"The object is to be a well patient, not a good patient"

Offline BM

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  • Posts: 340
Re: Adherence and Virological Rebound
« Reply #16 on: February 01, 2010, 06:39:41 PM »
Further to the sub-topic raised about reducing viral load quickly, I experienced a 2.67 log drop in 19 days on my second combination. I apparently had "archived resistance to my first combo, which is why I experienced quick failure.

Offline Inchlingblue

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Re: Adherence and Virological Rebound
« Reply #17 on: February 01, 2010, 06:45:12 PM »
The truth is that viremia is never fully suppressed

Not sure how you're defining "never fully suppressed," since there is residual viremia but it's worth noting that what residual viremia exists is not ongoing viral replication but rather virus coming from stable reservoirs so for all intents and purposes an effective HAART regimen suppresses viral replication 100%.

LINK:

http://www.thebody.com/content/treat/art50467.html

There are some studies (Chomont, et al) that have found in some individuals "replication" of the T(TM) cells carrying latent HIV without viral cytolysis (i.e. in the reservoirs not the plasma and it's not viral replication per se but a form of cellular duplication).

LINK:

http://pubget.com/paper/19543283?title=HIV%20reservoir%20size%20and%20persistence%20are%20driven%20by%20T%20cell%20survival%20and%20homeostatic%20proliferation.

http://www.natap.org/2009/HIV/011210_01.htm

http://www.natap.org/2009/HIV/011210_01.htm
« Last Edit: February 01, 2010, 08:40:08 PM by Inchlingblue »

Offline Assurbanipal

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Re: Adherence and Virological Rebound
« Reply #18 on: February 01, 2010, 08:18:17 PM »
I think clinically speaking the outcome of VL < 50 or VL <400 is relatively equivalent. The truth is that viremia is never fully suppressed so a VL of 130 is pretty much as good as a VL < 50 in my book. You could have very well be hovering at 47 (right below the limit of detection) so going from there to 70 or 130...  I'd still say that the drugs were working properly. I would probably go as far as saying that anything below 500 stable is great (that mimics elite controllers).

Note Inclhling's cites below on ongoing viremia.  The idea that I was hovering at 47 was attractive at first, but became quite unlikely after repeated blood draws. 

(The question of how one estimates the likelihood of a "true" level from repeated samples is pretty well addressed in statistical testing theory.  Briefly, if two standard deviations from a true level of 47 would be a three-fold increase (approx 150) the likelihood of 4 draws each showing a VL of 100 to 130 is vanishingly small.  There is more than a 50% chance that the "true" viral load in that case is a little above 100.)

Were you or your provider concerned at all with a viral escape when that happened?

Some, especially when it headed up in the second draw.  But when it appeared to be stabilizing at a very low level in draws 3 and 4...less so.  In fact if it weren't for the osteoporosis and lipids issues I might have stayed on the old regimen.


Absolutely. 100% is my goal.

Great!  There's a lot of learning to be done as new research evolves, but the most important thing you can personally do is to be adherent.  Frankly, if you have no resistance, choosing your first medication on ease of adherence rather than on the potential for side effects probably makes the most sense.  Sounds like you already have a few months under your belt and are going to do really well.
5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline BM

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Re: Adherence and Virological Rebound
« Reply #19 on: February 02, 2010, 04:51:18 PM »

Offline aztecan

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Re: Adherence and Virological Rebound
« Reply #20 on: February 02, 2010, 10:21:44 PM »
Hey BM,

I would agree with what Newt posted:


If you reach undetectable, like less than 50 copies, and stay there, the scenario you paint is unlikely if you have good adherence.

-matt


Although my evidence is purely anecdotal, I have seen a number of people, including myself, go many years without a viral rebound or breakthrough.

My viral load dropped to undetectable within three months of my starting meds and has stayed there, save one blip where the viral load was 61.

I started out with AZT, Epivir and Saquniavir, then switched out the Saquinavir for Crixivan in two months. I stayed on Crixivan, AZT and Epivir for 11 years.

For those familiar with Crixivan in the old days, that was something of a feat, or so I'm told.

I have switched meds several times since that first go round, always maintained an undetectable viral load and CD4s in excess of 900, usually more than 1,000.

So, in a long-winded way, I think the answer to your initial post is "yes."

HUGS,

Mark
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline hotpuppy

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Re: Adherence and Virological Rebound
« Reply #21 on: February 04, 2010, 02:55:03 PM »
I think clinically speaking the outcome of VL < 50 or VL <400 is relatively equivalent. The truth is that viremia is never fully suppressed so a VL of 130 is pretty much as good as a VL < 50 in my book. You could have very well be hovering at 47 (right below the limit of detection) so going from there to 70 or 130...  I'd still say that the drugs were working properly. I would probably go as far as saying that anything below 500 stable is great (that mimics elite controllers).

Were you or your provider concerned at all with a viral escape when that happened?

Great information.... but what is a viral escape?
Don't obsess over the wrong things.  Life isn't about your numbers, it isn't about this forum, it isn't about someone's opinion.  It's about getting out there and enjoying it.   I am a person with HIV - not the other way around.

 


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