When should I change?

If your viral load continues to rise, the earlier you change treatment (if you have this option), the less resistance will develop. This will make it easier to reduce viral load to undetectable again.

The earlier that you detect a rise in your viral load, the earlier you can do something about it.

The trend of your viral load results over time is still important. However, the longer you wait to check that a trend is emerging, the greater the chance that resistance will develop.

If viral load rebound is confirmed then your choices depend on several things:

• The drugs that you have already used.
• Your lowest ever CD4 count (called CD4 nadir) and current CD4 count.
• Your general health.

Some people change treatment if their viral load remains consistently detectable above 50 copies/mL.

At low levels – between 50 and 500 – you can sometimes intensify treatment, though this is generally not recommended. See ‘Intensify treatment’.

Another option is to wait until your viral load is confirmed at 500 copies/mL or higher. This will enable you have a resistance test.

In practice, many people have to start their next combination with far higher levels of viral load. This is often due to delays involved in checking whether viral load is really rising.

A higher viral load is more likely if you wait a long time between tests or do not get the results in ‘real time’ – i.e. two weeks after giving blood.

If you do not have enough new drugs for a new combination, then some drugs, even with a high viral load, are better to keep taking. They can help you remain healthy, sometimes for several years.

Nukes and PIs will continue to be active and are worth continuing. NNRTIs, T-20 and integrase inhibitors develop complete resistance, and are better to switch.

Waiting until new drugs are available is an important strategy. This is so that when you do change, it will be to a combination that is more likely to last.

This will stop you from using up each new drug as it becomes available in a weak combination that only lasts a few months.