How worried should I be?

[Pippet]

I just returned from the doc and I am still stumped about why I am not "undetectable" yet.   
My latest numbers were CD4 489, VL 383.  My CD4's seem to be going in the right direction but I just can't seem to lower my viral load to the <50 mark.
I'm wondering if there is something I can do differently that might improve my viral load.  I always take my Kaletra between 10:00 and 10:30 a.m. and p.m. accompanied by a multi vitamin and blood pressure pill in the morning and a Truvada at night.   I always take them with food and a glass of milk.  (The only way that keeps me from sitting on the throne all day.)  I eat healthy and get plenty of rest and exercise, but I also smoke a pack a day and have 3 or 4 drinks after work (5pm).

I'm going to try to change some of my bad habits, less smoke and drink.  But outside of that, I'm at a loss.

Any input would be helpful.
Pip

[newt]

There are two likely reasons why:

1. You are taking your drugs on time but not they are not absorbed by your body properly.

A test called Therapeutic Drug Monitoring (TDM) can measure the level of the Kaletra (but not easily the nukes) and see if this is so.  Your doc can order it for you.  It is relatively standard in the UK and Europe but not so common in the US.

2. You were resistant to some of the drugs before you started this combo.

A resistance test is not always a reliable predictor, especially of "hidden" nuke mutations that surface on treatment. If you do have resistance you would expect, in time, your viral load to rise -- but it may take some time.

What can you do?

There are 4 options (1) intensify (2) change (3) wait (4) stop short term and do a resistance test

In the absense of decent resistance data, intensify may mean add AZT (<< this a good but not certain bet) or another drug to reduce the final few copies of virus. Which drug and whether this is a good idea depends on doc's view on this.

In terms of changing it may mean using something new like Isentress (<< in addition to/as well as Kaletra) and/or Prezista (<< instead of Kaletra). Many options. Aside from 3TC/FTC, a completely new combo would be better than switching one or two drugs.

In terms of waiting, your viral load is steady now, and your CD4 count good.  This may stay like this for a loooong time.  The risk is accumulating (nuke) resistance (mainly). One reason to wait would be to have a completely new combo of very modern, resistance busting drugs.  And/or see if your viral load rises a little so you can do a resistance test on this combo (<< this is instructive because if any of the drugs are resistant being on the drugs will help the mutations show up on the test).

Stopping for a short while, maybe a week or so, so that you have enough virus to do a decent resistance test, may provide a more helpful guide to choice of alternative drugs.

Hope this helps

- matt

[Pippet]

Thanks Matt, for some very useful information.
My doc seems to have the "wait it out" attitude. He wants to wait until my vl rises to the point he can do a resistance test and then start over with a new regimen based on those results. 
The bad thing is that every option scares the shit out of me after all the crap I went through to find a combo I could "tolerate".

Thinking happy thoughts,
Pip

[Snowangel]

Hi Pip,
How is your stress level?  When I was going thru some big changes(company closing and child support issues) it really thru my numbers for a loop.  I wish you the best, try not to worry to much.  Good luck, Snow

[trellium]

what about intensifying the current treatment (Kaletra + Truvada) by increasing the daily Kaletra dosage and see if that will get the VL down to <50?

[redhotmuslbear]

Pip,
Cut back on the alcohol, then curtail the nicotene addiction.  Both of those drugs can work against your meds and your immune system, as well as in favor of the virus.

Best,
David

[ARMANDO]

i agree with RED HOT MUSCL,you have to cut down on the alcohol and the smoking.

[newt]

Obviously drinking less/not smoking are good things to do.  But alcohol does not affect how HIV meds work. Neither does smoking/nicotine.  These are unlikely to be factors in Pip's little bit of extra viral load.

- matt

[Miss Philicia]

Agreed.  Alcohol and smoking aren't really going to do squat in this situation.

I also agree with matt, and it was my first thought, about purposely bumping UP your viral load so that you can do a geno/phenotype test.  At least it's what I would do, even if your doctor doesn't want to.

[Pippet]

Thanks for all of the input.
There's no doubt that cutting back on my bad habits couldn't hurt the situation.  I will try to be better...  even though the first thing I want to do when I stress is have a beer and a cig. 

I am a little concerned about my "every 3 months" blood draws.  My vl doesn't seem to be going up or down at this point, but if it decides to spike how quickly will it do so?  As you know, blood draws and doc visits etc get very expensive, very quickly.  Even with my so called health insurance.  Being the main reason for every three months.

I will talk to my doc about letting my vl rise a bit to get a resistance test ran.  My last doc was an idiot who had me taking Truvada 'alone' for awhile to make sure it was the Viramune I was allergic to, and then Truvada and Rayetaz without the Norvir boost.  He might have caused some resistance somewhere.  I haven't had a resistance test done since before I first started meds.

Thanks again,
Pip

[newt]

Going every 4 months saves 1/3rd the cost of the tests.  You can judge whether an extra 4 weeks will make a difference in a good way or bad way. The important tests to concentrate on right now are viral load and resistance. It may take a while to see a rise to around 1,000 copies on the viral load, which is the minimum you need for a decent resistance test.  Indeed it may take ages and ages, like many, many months. No way to tell.

- matt