2. Reasons viral load can rebound

Your doctor will need your help to find out which of the reasons below are most important.

REASONS A COMBINATION CAN FAIL	WHAT TO DO ABOUT IT
1. Lab error.	Small increases in viral load might just be normal fluctuation or a lab error.	Retest viral load as the next test might be undetectable again.
2. Recent infections or vaccinations.	If you have recently been ill, other viral infections can sometimes cause small increases in HIV viral load. Some STIs might cause this. Vaccinations can also cause more viral activity that causes an increase.	Take to your doctor about your recent health and any vaccinations. Retest viral load after four weeks.
3. Information.	Maybe you did not have enough information. Or did not understand how to get the best from your meds.	Take control of your own health. Ask questions about treatment until you are happy with the answers.Talk to your doctor, health advisors and friends. Read leaflets and websites. Ask for help.
4. Adherence. You might have missed doses or been late taking your meds.	Your doctor is likely to talk about adherence first.	Be as honest as you can when discussing this.If you did not miss doses it is important that your doctor believes you. See these tips.
5. Taking meds with or without food.	Some drugs need to be taken with food and others without food to reach the right levels.	Check that you had the right information. Not following this advice might mean you were only getting half the dose.
6. Low drug levels. You were taking your drugs on time but they were not absorbed properly.	Some people absorb low drug levels.This is less common with modern meds but may still be worth checking..	Drug levels can be checked for most drugs except NRTIs (*nukes”).
7. Drug resistance before treatment.	Resistance might have been missed before you started. Even taking all your meds on time can’t overcome drug resistance.	Get a new resistance test and an expert review of previous tests.This will help choose your next drugs.
8. If your combination had side effects.	No matter how good your combination is, if you have difficult side effects, or it is too difficult to take, then ask if there are other options.	Use new drugs that are still likely to be active. If side effects were a reason you missed doses, your doctor needs to knows.There are likely to be other meds you can use.
9. Drug interactions. These might have reduced the drug levels of your HIV drugs.	Other medications or supplements can interact with HIV drugs.This includes meds you can buy over the counter without a prescription.It can include vitamins and minerals and some recreational drugs.	Your HIV doctor and pharmacist need to know about all your drugs and supplements. This is to check for potential interactions. See: www.hiv-druginteractions.org
10. The drugs in your ART.	Some drugs are not recommended at high viral loads.	Check that the drugs in your last combination were right for your viral load.
11. HIV reinfection (superinfection)	You were reinfected with a new strain of HIV that is resistant to one or more of the meds in your combination.	This is not easy top test for but a drug resistance text might explain treatment failure after good adherence for many years,
12. Viral load is being produced and released from the reservoir.	Some people report low-level viral load despite perfect adherence that doesn’t reduce further when adding a new drug or changing treatment, See Halvas et al.	This is difficult to identify but is important fir your doctor to consider.

REASONS A COMBINATION CAN FAIL

WHAT TO DO ABOUT IT

1. Lab error.

Small increases in viral load might just be normal fluctuation or a lab error.

Retest viral load as the next test might be undetectable again.

2. Recent infections or vaccinations.

If you have recently been ill, other viral infections can sometimes cause small increases in HIV viral load. Some STIs might cause this.

Vaccinations can also cause more viral activity that causes an increase.

Take to your doctor about your recent health and any vaccinations.

Retest viral load after four weeks.

3. Information.

Maybe you did not have enough information. Or did not understand how to get the best from your meds.

Take control of your own health. Ask questions about treatment until you are happy with the answers.Talk to your doctor, health advisors and friends.

Read leaflets and websites. Ask for help.

4. Adherence.

You might have missed doses or been late taking your meds.

Your doctor is likely to talk about adherence first.

Be as honest as you can when discussing this.If you did not miss doses it is important that your doctor believes you. See these tips.

5. Taking meds with or without food.

Some drugs need to be taken with food and others without food to reach the right levels.

Check that you had the right information. Not following this advice might mean you were only getting half the dose.

6. Low drug levels.

You were taking your drugs on time but they were not absorbed properly.

Some people absorb low drug levels.This is less common with modern meds but may still be worth checking..

Drug levels can be checked for most drugs except NRTIs (*nukes”).

7. Drug resistance before treatment.

Resistance might have been missed before you started. Even taking all your meds on time can’t overcome drug resistance.

Get a new resistance test and an expert review of previous tests.This will help choose your next drugs.

8. If your combination had side effects.

No matter how good your combination is, if you have difficult side effects, or it is too difficult to take, then ask if there are other options.

Use new drugs that are still likely to be active. If side effects were a reason you missed doses, your doctor needs to knows.There are likely to be other meds you can use.

9. Drug interactions.

These might have reduced the drug levels of your HIV drugs.

Other medications or supplements can interact with HIV drugs.This includes meds you can buy over the counter without a prescription.It can include vitamins and minerals and some recreational drugs.

Your HIV doctor and pharmacist need to know about all your drugs and supplements. This is to check for potential interactions.

See:

www.hiv-druginteractions.org

10. The drugs in your ART.

Some drugs are not recommended at high viral loads.

Check that the drugs in your last combination were right for your viral load.

11. HIV reinfection (superinfection)

You were reinfected with a new strain of HIV that is resistant to one or more of the meds in your combination.

This is not easy top test for but a drug resistance text might explain treatment failure after good adherence for many years,

12. Viral load is being produced and released from the reservoir.

Some people report low-level viral load despite perfect adherence that doesn’t reduce further when adding a new drug or changing treatment, See Halvas et al.

This is difficult to identify but is important fir your doctor to consider.