Taking ART before or after viral load test?

[awakening]

I have had two blips this year. 100% adherence. Anyone ever receive advice from doctors about whether it makes a difference to take ART before or after an early morning viral load test if the daily dose is normally taken each morning?

[Jim Allen]

No it would not really make sense to me as basically ARV simply do not kill the virus or change VL counts directly.

So if you had a detectable viral load on the morning of the test, taking the meds before the test would not kill that viral copy. The meds would just stop it from being able to infect another cd4 cell / prevent HIV from "being copied" leaving it homeless to die off so to speak. 

Here is the basic life-cycle of HIV, the meds simply interrupt one or more of the steps to prevent the life-cycle. They don't kill directly the HIV copy. https://www.poz.com/basics/hiv-basics/hiv-life-cycle

Are you asking because of the 75 VL count? What did your doctor say about this?
 
Jim

[awakening]

Thanks for the explanation. Although the doctor acknowledged it could just be another blip (the 75) he wants me to retest now a month later. From his experience it's unusual to see this with Triumeq in someone ART naive with perfect adherence.

[Jim Allen]

Its really good to hear your doctor is staying on top of it, and its just a single snapshot moment you will always have some variances between moments, I would nearly say low level (clinical) Viral load blips above 50 are common enough.

It might be different if you were having constantly blips or larger blips in the 200+ ranges but this by the sounds of it just a minor clinical blip nothing more. So nothing to worry about or to loose any sleep over.

Keep us posted and let us know how things go on when you retest but personally I think you will be fine.

Jim

https://www.poz.com/article/viral-blips-raise-risk-hiv-treatment-failure

http://www.aidsmap.com/Viral-blips/page/1729801

[awakening]

My viral load retest results were "<20", so it looks like the 75 was just another blip.

Maybe I'm just more prone to blips than some? My lab distinguishes between <20 and "undetected." I know for all intents and purposes they are the same, but I wonder if my medication somehow isn't completely able to put the beast to sleep.

[Jim Allen]

Excellent.
 
What did the doctor say ?

We all blip :-) I just don't get measured often enough to capture them, its two minor clinical blips over your entire duration on meds and its not a concern and I say clinical blip as clinically speaking under 50 is undetectable even though lots of labs can be more accurate than that. 

On the more recent studies into transmission I believe the UD threshold was set higher at anything under 200.

You are doing fine, the drugs you are you can take with or without food (https://www.poz.com/drug/triumeq) so if you are really concerned you could try taking it with a bigger meal as dolutegravir blood plasma levels increase however with that come also with possible pitfalls and you should talk to a dotcor first.

Ill try and find you a link when I am back at my laptop but to me it sounds like your treatment is going fine and you have nothing to worry about so why change things or loose sleep over it.

Jim

EDIT including links:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805712/
Clinical Pharmacokinetic, Pharmacodynamic and Drug-Interaction Profile of the Integrase Inhibitor Dolutegravir

http://www.viivhealthcare.com/media/74706/EU_Tivicay.pdf
Absorption  Dolutegravir is rapidly absorbed following oral administration, with median Tmax at 2 to 3 hours post dose for tablet formulation.   
Food increased the extent and slowed the rate of absorption of dolutegravir.  Bioavailability of dolutegravir depends on meal content: low, moderate, and high fat meals increased dolutegravir AUC(0-) by 33%, 41%, and 66%, increased Cmax by 46%, 52%, and 67%, prolonged Tmax to 3, 4, and 5 hours from 2 hours under fasted conditions, respectively. These increases may be clinically relevant in the presence of certain integrase class resistance. Therefore, Tivicay is recommended to be taken with food by patients infected with HIV with integrase class resistance

https://www.poz.com/drug/tivicay

[leatherman]

We all blip :-)

and some of us more than others. For myself, it seems every couple of years I go through a blipping period.

I had blips of 375, 970, 1250, 2500 over a 2 yr period during years 7-9 on my first really good regimen (lasted for 10 yrs with no barfing, no sides, good numbers....well, except for those blips LOL). Then just as I talked to my doctor about changing to a new regimen (for fewer pills and fewer sides) I blipped to 7800 and 59000 over a 4-month period! (and with a cd4 drop back <200, I had da aides again! oh noes!)

I had a genotype done while I had that high VL and, what do you know, but my meds were still effective! Sure enough, by the next VL test I was back to UD. So it wasn't treatment failure and it wasn't med resistance. It was just another blipping episode. LOL I went ahead with the med switch (since it had never been about the blips, but simply pill reduction) and after a year and a half, I've had no blips and just obtained my highest cd4 count (441) in 25 yrs of testing. Although to be honest, my last VL test did not come back "UD" as it usually does, but as "<20", so maybe I had a micro-blip. LOL (speaking of which, we've had some discussions before about "micro-blips"™, so you might want to search for that...did the search for you   https://forums.poz.com/index.php?topic=63627)

what's the one thing I've learned about HIV after nearly 2 decades in these forums? It's effects are always a little different for everyone.The other thing I learned? It's about the trends - the trend of your viral load, the trend of your cd4 count - and trends are at least 3 tests spread out of a reasonable amount of time e.g. several months. Is the trend (no matter how jaggy, like mine has been at times) up or flat? no worries then Is it trending down? then be concerned, but don't worry , and talk to your doctor.

[leatherman]

after just checking your posting history, awake, I would also make another comment. Seeing as you're basically in your first year of treatment, sometimes getting a VL down to a sustained UD is not always a straight line trend. A lot of people will have bouncing VL counts for a while.

Is it nerve-racking? yes. Is it unusual? not so much. 

[Jim Allen]

It can also happen when dealing with other illnesses like the flu etc. to have a micro blip. Again as everyone is saying nothing to worry about, just a single snapshot moment and some variances between moments can happen, its not a trend

Jim

[awakening]

Thanks all for the information and support. My doctor says no worries, continue on with Triumeq, see you in 4 months. He says that even though the lab sometimes lists UD and sometimes <20, they are one and the same for his purposes (UD).  I realize I'm in good shape relatively speaking and fortunate to have access to powerful meds with no obvious side effects. I think I found myself comparing my results to others I see on here where some talk about having been UD for years in a row. I was just hoping to get on a roll with being UD for some time before having two blips in one year. to build confidence that I am stable. But I realize there is no immediate danger to my health, my CD4 count nor an ability to pass on the virus to others.

My tests are many months apart. I wonder if I tested everyday what percentage would be <20 and what percentage above? Just because I test at 75 doesn't mean I've been 75 for the last month. Maybe I've been <20 for most of the month, maybe it's been a bit higher, who knows? It's just a snapshot in time so there's some aspect of a roulette game to what result you get. I shared research in an earlier post about how when they test HIV+blood daily, the results varied widely and when the same blood was tested in separate labs, rarely did they get the same results.

The unsettling part I think for me is the the low viral load numbers remind me of the latent reservoir that persists and wonder if even that low level of activity (even if below 200) indicates more long term inflammation. But nothing I can do about that except take the pill, take care of myself and live.

[Jim Allen]

nothing I can do about that except take the pill, take care of myself and live.

This should be your only thought, the rest is just "what if's" and that no real world impact or at least you can't change it anyway, so no point concerning about it.

You are only a year into this and a case of what if's and worrying about blips can happen, its normal i suppose. Look it will get less and less with time, until finally you never think about it as you will be too busy living your life. 

Jim