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Author Topic: Up and downs with Viral Load  (Read 1468 times)

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Offline jonsi

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Up and downs with Viral Load
« on: January 17, 2012, 01:10:30 PM »
Hi everyone!

I started in June with Atripla, when i had a viral load of over 400K, and CD4 of about 150. In October my VL went down to 54(!!!) so doc was really happy. My CD4 also went up to about 400.

My latest results were yesterday and while my CD4 is at 590, my VL for some reason went up to 3500... The doc. wasn't sure about it, but he told me not to worry. But, should I worry? I've never been the number kinda person, so I'm not really that worried, it'd just be horribly annoying if I have to change to another drug(s) after I finally got used to to this one.

Anyone has had similar experiences? Maybe something went wrong at the lab? (that's what my doc. said could have happened)

Thnx! :-)
ţetta er ágćtis byrjun...

Jónsi.

Offline Ann

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Re: Up and downs with Viral Load
« Reply #1 on: January 17, 2012, 03:00:00 PM »
Jonsi, five years ago when you first joined the forums you were taking Sustiva and Truvada - the same meds as in Atripla. Did you go straight from taking Sustiva and Truvada to taking Atripla, or did you have a treatment break some time in the past five years?

If you did have a treatment break, it is possible that if you didn't stop correctly you could be resistant to the Sustiva (you should have continued with the Truvada for a couple days after stopping the Sustiva).

Could we please have some more details of your treatment history? Thanks. You will have more informed responses if we have details.
« Last Edit: January 17, 2012, 03:02:38 PM by Ann »
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Offline jonsi

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Re: Up and downs with Viral Load
« Reply #2 on: January 17, 2012, 04:17:06 PM »
Hi Ann,
Thanks!

I did stop for over a year (maybe year and a half) after discussing with my doctor atm. I then decided to start treatment again in June after it seemed to have not been a really good idea. It might have been that but what is puzzling is that the VL seemed to go so far down, which my doctor saw as a good sign and so back in December (last time I talked to him before my last blood test 2 weeks ago) he was very optimistic that everything was fine. Yes, back in Dec it as just a general check up, so no blood tests, the last ones were in October.

Also, back then, when I stopped, or as they call it, "had a vacation", it was mainly for side effects and the fact that the VL showed undetectable for quite a long time. This time I've had no major side effects, which i was really glad about, but now I do hope this is not a sign of resistance and have to see how something else affects me.

Thank you!
ţetta er ágćtis byrjun...

Jónsi.

Offline newt

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Re: Up and downs with Viral Load
« Reply #3 on: January 17, 2012, 05:33:19 PM »
When you stopped Sustiva and Truvada did you use any other meds for a short while?

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

Offline jonsi

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Re: Up and downs with Viral Load
« Reply #4 on: January 18, 2012, 04:44:48 PM »
Hi Matt,

Nope, I did not take any other meds.

ţetta er ágćtis byrjun...

Jónsi.

Offline newt

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Re: Up and downs with Viral Load
« Reply #5 on: January 18, 2012, 06:21:01 PM »
OK

The bad news is you have a 50% chance of being 100% resistant to efavirenz (eg one of the meds in Atripla) and some related meds << this would explain the sudden rise in viral load. The good news is it might be a duff test (a blip) << this would also explain the rise. I would get a resistance test and a repeat viral load.

For other people, the best way to stop efavirenz (ie avoid resistance) if you want to perhaps one day use efavirenz again is to take some other meds for 2-3 weeks. Either A boosted PI + 2 nukes or just 2 nukes. Efavirenz lingers, and can remain at low levels in the body for 2-3 weeks, which allows HIV to adapt and evade it when reused. Using other meds for a short while usually preserves efavirenz (and nevirapine) as options for re-use. For people with African genetic heritage (not always obvious) a month's cover with other meds is better. PIs and/or 2 nukes are used because they do not linger, therefore avoid the risk of resistance in nearly all cases.

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

Offline eric48

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Re: Up and downs with Viral Load
« Reply #6 on: January 18, 2012, 06:39:27 PM »
So you are 6 months into treatment, but not really a treatment naive... Is this correct ?

The VL at 54 in Oct (3-4 months into treatment) and VL 3500 now (6 months into treatment) seems the only data you have on your latest round of meds ?
Is this correct ?

Vl at 54 at month 3 falls within the frame for virological success (as per the protocol where I live, which is more strict than the one in the US)
If you were treatment naive, and leaving in the same place I do, your VL 3500 would be qualified as virological failure.

But you are not treatment naive...

VL this the fingerprint that PREVIOUSLY infected CD4s leave behind them as they die.

At months 3, no much VL was left because your did not have many CD4 to start with (after 3 months these 150 CD4s have died and been replaced by others)

These new ones (500! mind you, a gain of 350...) may not come all out from scratch. It is such a rapid increase that you ** may** think that these comes from
1- brand new (uninfected) CD4s (at month 6 that gain is average 100)
2- older (infected) CD4s that have multiplied (expanded) (for some reason, like a flu) and would contribute to the remaining 250

Hence possibly a second wave of VL that **may** result from the strong CD4 dynamics and not necessarily be a sign of non-suppression of replication by the meds.

This is very hypothetical, and I have no expertize in this, but may be the reason why you doc was not too worried.

But as mentioned by Matt, resistance could be the cause (Matt answered, while I was typing, so my comment may be out of sync)

I do not know how my doc would have handled this, but one thing is sure (because a rebound had happened to me), I think my doc would have ordered an additional resistance test
on you latest blood draw. At VL 3500, it can be done... It is an extra cost (ca $700), but here, I think they would do it, just to be on the safe side.

My doc, at one time, was worried that I might have resistance (I did not, as it turned out), I think he mentioned 181 (? can't remember), but he did mention that that one is a nasty one that one would really want to avoid and stamp ASAP by all means.

I do not know if you have a chance to push a request for a resistance test. It can be done even several month after the blood draw , as the lab should keep the samples for a year.

Hope this helps

Eric
« Last Edit: January 18, 2012, 06:43:08 PM by eric48 »
NVP/ABC/3TC/... UD; CD4 > 1000; CD4/CD8 ~ 2.0   safety stock : 3 months (2013: FOTO= 5d. ON 2d. OFF)

Offline buginme2

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Re: Up and downs with Viral Load
« Reply #7 on: January 18, 2012, 06:43:29 PM »
OK

The bad news is you have a 50% chance of being 100% resistant to efavirenz (eg one of the meds in Atripla) and some related meds << this would explain the sudden rise in viral load. The good news is it might be a duff test (a blip) << this would also explain the rise. I would get a resistance test and a repeat viral load.

For other people, the best way to stop efavirenz (ie avoid resistance) if you want to perhaps one day use efavirenz again is to take some other meds for 2-3 weeks. Either A boosted PI + 2 nukes or just 2 nukes. Efavirenz lingers, and can remain at low levels in the body for 2-3 weeks, which allows HIV to adapt and evade it when reused. Using other meds for a short while usually preserves efavirenz (and nevirapine) as options for re-use. For people with African genetic heritage (not always obvious) a month's cover with other meds is better. PIs and/or 2 nukes are used because they do not linger, therefore avoid the risk of resistance in nearly all cases.

- matt


Good info, thanks!

Offline mecch

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Re: Up and downs with Viral Load
« Reply #8 on: January 18, 2012, 08:37:14 PM »
Also, back then, when I stopped, or as they call it, "had a vacation", it was mainly for side effects and the fact that the VL showed undetectable for quite a long time.

Unsolicited observation:

I thought it was generally agreed that

1) once started on HAART, the response and hopefully solution to side effects is trying different combinations.

2) the point of HAART is having an undetectable viral load, forever.  That is success. Not reason to take a "vacation".   But then, I guess a few years ago the idea of a holiday still had currency.

Well anyway that's what I understand to be current wisdom.
« Last Edit: January 18, 2012, 08:39:44 PM by mecch »
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline jonsi

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Re: Up and downs with Viral Load
« Reply #9 on: January 19, 2012, 01:55:46 PM »
Hi all!
Thanks for all the great replies :-)

As I said previously, taking a vacation was decided by me and the doctor (he gave me the options of what I could do, and while I thought I might regret, I thought what I really wanted at that moment was stop altogether).

The doctor is still not too worried, although he didn't really explain his reasons not to be worried. I think it's not a complete failure yet and would like to take things from a scientific point of view, and the results of only one test might not be enough to get to a conclusion of resistance.

I think the doc will be asking for a resistance test if he thinks it's necessary after the next VL count, which will be in April. I live in the Netherlands, and, thankfully, the cost is not an issue as it is covered by the insurance.

It is quite nice to get so many responses! It's highly educative, since sometimes I feel doctors can be quite short on replying to my questions, especially in this country where it seems you have to drag the answers (sometimes even the treatments) out of the doctors because they don't seem too bothered.

I'll post the next results, as I think it could help anyone who wants to have some information on the subject.
 :)
ţetta er ágćtis byrjun...

Jónsi.

Offline eric48

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Re: Up and downs with Viral Load
« Reply #10 on: January 19, 2012, 03:47:04 PM »
Hi,

If indeed it has become a 'manageable' conditions a number of decisions may require management skills as much as medical education.

vacation may not be such a bad idea after all, if you are under competent medical supervision and young enough to rebuild an immune system quickly.

For 'older' people like myself the dynamics are slow and I would be more carefull in such a case.

Risk Management...

BTW, you may be able to order a VL test for ca $50 even without a prescription.
This is what I would do 6 weeks after the VL3500 test and not wait another 12 weeks. A $50 intermediate test may help you in better monitoring and better understanding of your docs decision when April comes.

Risk Management... Again... and you are the decider...

Good Luck any way

Eric
NVP/ABC/3TC/... UD; CD4 > 1000; CD4/CD8 ~ 2.0   safety stock : 3 months (2013: FOTO= 5d. ON 2d. OFF)

 


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