Question
What are my options with a low level viral load result on dolutegravir?
14 September 2016. Related: Adherence, All topics, CD4 and viral load, Changing treatment.
So i’ve been diagnosed for a year now with my viral load dropping from 200,000 to undetectable in a month on raltegravir and Truvada. In May of this year i changed treatment to Triumeq as i found i occasionally missed the evening dose of raltegravir (Although i was still undetectable) and my doctor thought changing to the once a day pill would help overall.
Taking the pill once a day did make it much easier and I had less anxiety about being out incase i didn’t get home in time to take it.
Since starting Triumeq my viral load has become detectable again. Since May it rose to 27 in July and my latest result, yesterday, it was at 154 which seems like quite a steep rise?
The doctor doesn’t really understand why it has risen as i haven’t been taking anything such as vitamins that could react with the Triumeq, i haven’t been unwell and i don’t have any other STIs.
I take the pill roughly the same time every day with a window of about 1-2 hours. Occasionally i forget and maybe take it about 4 or 5 hours out and i’ve forgotten to take it maybe twice in 2 months. But this is similar to how i took the raltegravir/Truvada, in fact i’ve probably been more strict with times with the Triumeq. I assumed once i was undetectable it wouldn’t matter so much if i was out by a few hours.
The doctor said that if ive become resistant that rules out going back to my original tablets as they’re in the same class as Triumeq, so would that mean i’ll be on older medication with more side effects?
Should i be worried about the rise in my viral load? And is it possible i’ve become resistant even though i’ve taken my pill more or less every day?
It’s really worrying me as being undetectable made me feel better about the virus as it meant i’m not infectious. For now though i’ve been advised to be super strict with times for the next month until i revisit the clinic.
Answer
Thanks for the detailed info in your question and for letting us answer this online.
Also, knowing you are treated in the UK makes a big difference because it is easy to recheck your viral load every 2-4 weeks.
Although on paper these result look like increases, this isn’t necessarily what is happening.
- One or both could be a lab error.
- One or both could be a blip – i.e. small temporary increase that will go down again without needing to change meds.
As you are in the UK, your doctor should repeat the viral load test now or in 1-2 weeks. It is good that your doctor doesn’t want you to wait for wait for three months, but earlier than a month might be better.
It is also important to take every dose at the same time (within the window of an hour or so) until this is better understood. Also, although it is not in the guidelines or package insert, you might want to take dolutegravir with a meal that includes some fat in order to boost drug levels. See: https://i-base.info/guides/8851.
Higher drug levels make dolutegravir more potent against the virus. When there is a concern about drug resistance, dolutegravir is prescribed twice daily (i.e. every 12 hours) so this might also be a short-term option.
If you have perfect adherence with once-daily taken with food and the viral load is higher than 200 with the next viral load, then it is worth getting a resistance test (including for integrate) and discussing about either switching to twice daily dolutegravir or to a different combination. Resistance test can still work when viral load is below 500.
One reason to be hopeful, is that blips have been reported in dolutegravir studies which resolved without changing treatment – even when changing treatment was recommended.
Given the overall cost of your treatment, it is fine to have a few more frequent viral load tests now until this is resolved.
If this is a real viral rebound, the risk of waiting a month is that this increases the risk that more serious drug resistance could develop over this time.
Hi Kitty,
Sorry to hear about your diagnosis along with the good news that you’re having a baby.
We are not doctors at i-Base. So it’s a good idea to ask your doctor about getting your viral load to undetectable by the time you deliver your baby.
But what does your doctor say about taking all these meds? Do you have access to your CD4 count?
Ive recently found out im hiv positive n im 33 weeks pregnant my doctor says my viral load is 2900..he recently started me taking triumeg pill daily, 2 shots of fuzeon every 12 hrs n on zidovuine every 4…what are the chances of my viral load number dropping n what would be the range today?
Hi Heide, could you send more details – ie how high is your viral load and which country are you writing for. What does your doctor say about this. As long as viral load is still low, the risk to your baby will also be low, but this might change the choice for whether you have natural birth or C-section. It is okay to email me directly if you prefer: simon.collins@i-base.org.uk.
I am having the same problem with my viral load being detectable when it never has before and I have been taking Triumeq since 2015. Now I am pregnant (7 months) it’s detectable. Is there a link with pregnancy? Will my baby be at risk? I am scared and this is an understatement.
Hi Jon, thanks for getting back with more details. These viral load levels are still very low – and the test is not always so sensitive at very high and very low levels. In US guidelines, a viral load that is under 200 is still referred to as undetectable. Good you have had a nice CD4 response too.
High fat breakfast foods include full fat milk, yogurt, cheese, fried food (ie a fired breakfast), most nuts, crisps, chocolate, butters and oils, peanut butter, pastries, croissant, etc.
Nearly all main meals – whether lunch or dinner are likely to also have a high fat content. Have a look at food labels when you are next buying food in the supermarket. It might be easy to take Triumeq with one of these meals to get the best benefit.
The study that showed the food impact used three closely defined meals:
(i) low-fat (300 kcal, 7% fat)
(ii) moderate-fat (600 kcal, 30% fat), and
(iii) high-fat (870 kcal, 53% fat) meal.
When a single dolutegravir was taken with these three meals overall drug exposure increased by 33%, 41%, and 66%, respectively,
So even a low fat snack will increase levels by one third and a high fat meal but two thirds.
Here is a link to the first calorie/fat food list that I found online – I am sure there are hundreds of other that you can find if you want more:
http://www.myfoodbuddy.com/foodCalorieTable.htm
Here is the link to the food interaction study – though it is quite a technical article.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294934
Thanks for the quick and detailed reply, the doctor did retake my viral load test the day I got these results and took my CD4 count. I’ve just got the results and its gone up again to 176 with a CD4 of 680. I’m going back in about 3 weeks but she just said to keep taking the triumeq at the same time.
She didn’t advise taking it with food but if this increases drug levels I’ll try. I take it in the morning and rarely have breakfast, so without sounding stupid what counts as a high fat meal I could eat in the morning?
Thanks
There are lots of question about this at this link:
https://i-base.info/qa/?s=life+expectancy
Hi there I’m HIV positive and how long can I stay alive