Question
How can VL go down before ART and can I get single pill ART in the UK?
10 November 2017. Related: Access to treatment, All topics, CD4 and viral load, Starting treatment.
Hi there,
I’m 23, living in the UK and was diagnosed in March 2016 with CD4 count of 350 and viral load at 33,000.
I’m still not on treatment due to personal reasons but after almost 18 months I have finally decided to start medication. I just visited the clinic been told my VL is 25,000 and still waiting for CD4 results. I have two questions…
1. Please could you explain how it is possible to have lower VL lower after 18 months NOT on treatment.
2. Regarding treatment, Ive been told I can’t start a single pill regimen because UK doesn’t provide single tablet regimen anymore due to financial reasons from the government.
I was expecting really high VL. And really disappointed to found out there’s no single tablet regimen available anymore in the UK.
Answer
Hi
Thanks for writing – two great questions :)
The pattern of viral load is usually that a few weeks after infection, viral load becomes very high – sometimes to more than 10 million copies/mL. This is the time when people get symptoms – and are also very infectious.
But then, even without treatment, the immune system fights back and brings viral load down to much lower levels – usually to less than 50,000 but sometimes lower than 10,000.
If your diagnosis was relatively soon after infection, your first viral load test might either have been caught in the initial increase or the immune-related drop afterwards. If, for example, it was still on the way down, your results at 33,000 might have dropped to 5,000 a few months later. It is then likely to have been steadily increasing from that low point to the 25,000 it is now.
Another explanation is that over most of this time your viral load might have been pretty stable. There is a large margin of error for viral load results that mean technically, 33,000 and 25,000 are statistically about the same. Actually for a result of 30,000 the real figure could be anywhere from 10,000 to 90,000 and still be technically the same.
Your second question also has a slightly complicated answer.
Some people in the UK are still using combinations where three or four meds are in a single pill. All these combinations will continue to be used by some people in different circumstances.
One of the recent changes though is that some of the individual drugs in these single pills have come off patent, with generic versions costing perhaps 90% less. Some manufacturers of the single pills have lowered the single-pill price to reflect this change in the market, but other companies haven’t.
So depending on the combination that your doctor is recommending – or better still, the choice your doctor is giving you to choose from – this might still be include a single pill option, or might just require two pills a day.
Given the savings to the NHS, most HIV positive people think there is not much difference between taking one pill a day or two pills a day – so long as the drugs are effective, safe and and can be both taken at the same time.
A few regional differences also affect choice of ART in the UK. So the seven regional health authorities (four in England, one each for Wales, Scotland and Northern Ireland) can have slightly different commissioning policies and guidelines. Some regions still include single pill combinations and others recommend splitting to allow generics components.
It is good you are now starting treatment though. Actually guidelines would have recommended this 18 months ago, but for complicated reasons not everyone decides to do this.
How are you doing now? Finding out you are positive can be tough and even after 18 months I am sure that things might not always be easy.
If you would like more information – or to talk about your individual choices – please comment below or email back. Or call the i-Base phoneline where we can give individual advice depending on your circumstances and where you are getting your care.
https://i-base.info/qa/phoneline
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