Q and A

Question

Is it normal for VL to drop from 4 million to 200 but then increase again?

My stats and journey so far include the following approximate results and times.

1. 1st week Nov 2019 – CD4 15 & VL 4.8 Million
2. 3rd week Nov 2019 – CD4 45 & VL 2,200
3. Mid December 2019 – CD4 80 & VL 626
4. Mid Feb 2020 – CD4 78 &VL 206
5. End May 2020 – CD4 206 & VL 506

I had a genotype test in November and my HIV was not resistant to Biktarvy 

I’m very concerned that my viral load has gone back up while on Biktarvy. However I am thankful to have CD4 now over 206.

My questions are as follows:

1. Is it normal for the viral load to go back up as it has since I started so high before becoming undetectable?

2. What has been your experience with getting your viral load under control starting with such a high number?

3. Should I be concerned that its now trending upwards but my CD4 is improving or is this a probably just viral blip of some sort?

Please help – I’m 100% adherent to my medicine. I just really want to get this to undetectable. I dont want to panic but I will not lie this is very concerning for me. Please provide your experience.

Answer

Thanks for including so much detail in your question. This makes it much easier to answer each question specific to your situation.

Firstly, viral load does not normally go back up again. The usual pattern after starting treatment is for viral load to steadily get lower until it becomes undetectable.

There are two possible explanations:

  1. This might be a lab error and viral load is still in the low hundreds – because technically there is not a real difference between 200 and 500.
    or
  2. It might be a genuine viral rebound that is increasing from 200 to 500 because of low level drug resistance.

The only way to tell which of these is the cause is to have another viral load test now and also another resistance test. This is what would be done in the UK.

For your second question, patterns are sometimes different when viral load starts higher than 1 million c/mL. Actually, some people diagnosed in very early infection can have more than 10 million c/mL. Such high viral loads are much more rare in people in late infection, that I assume is your case because of the low CD4 count. Sometimes for reasons that are not fully explained, some people just take longer to get undetectable though – but more frequent monitoring is then recommended.

Finally, I think you should try to manage everything very carefully until your viral load does become undetectable. You are right that it is very good that your CD4 count is not above 200. This will reduce your risk of becoming ill from HIV.

However, CD4 changes usually lag behind viral load. If your viral load has developed early drug resistance and you don’t change treatment, the viral load will continue to increase and then your CD4 count will drop again later.

If drug resistance does develop, then changing your combination now is much better than letting more resistance develop.

By checking now, you might also be lucky and find that your viral load has continued dropping again. This is what would happen in the UK.

This online guide on viral load rebound has much more detail about your situation.
https://i-base.info/guides/changing

It is really good that you have been so good with taking your meds. Please emphasise this to your doctor. Sometimes when results are not ideal, doctors wrongly put this down to adherence. Your doctor needs to trust you and realise this is not the cause of your current results.

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