Question
Why can’t I achieve an undetectable viral load?
25 November 2023. Related: Adherence, All topics, Starting treatment.
I started my treatment with Biktarvy in September 2022. My viral load was 1.6 million, and my CD4 count was 275 at the beginning. After one month, my CD4 count increased to 600, and the HIV RNA count decreased to 4300. At the end of 11 months, my CD4 count was around 800, but my HIV RNA count never dropped below 400 during this time. My viral load fluctuated between 400 and 1200, but my CD4 count remained consistently between 700 and 800.
Upon noticing this, my doctor suspected that I might have developed resistance to the medication, and consequently, they changed my prescription to Prezista+Norvir+Tivicay. A resistance test was conducted, and no resistance was detected to Biktarvy or the new medications. However, after three months, my HIV RNA result is still in the 600 range, and I have not achieved an undetectable status. I seek assistance in understanding the possible reasons for this. Thank you.
Answer
Hi, how are you doing?
It is great that your tests shows that you don’t have resistance to your treatment and your CD4 count is great.
Unfortunately in some people it is not possible/very difficult to achieve an undetectable viral load.
Factors that increase this likelihood inc. being male, prior exposure to ART, earlier in treatment course, < 15 years old, low BMI being on Tb treatment.
Of what has been mentioned the only factor that has increased your likelihood of not being able to obtain an undetectable viral load is you are still early in your treatment course.
Around 20% of patients on first-line therapies after starting treatment can be seen to still have a viral load greater than 1000.
In these cases it is important for other factors to be addressed in helping achieve an undetectable viral load e.g., improving nutrition, having a healthy BMI, assisting in adherence….
How often are you having your viral load tested? When having difficulty achieving an undetectable viral load it should be measured every 3 months to assess for other factors that could be causing a problem.
Josh.
Hi Thomas, it is great that you were able to start treatment same day and your viral load has responded so well.
Even though it had taken 2 years to achieve a viral load < 20, having a viral load below 100 within 4 months is excellent. When below 200 viral load is considered undetectable.
I got Diagnosed in December 2021. Started Therapy on the same day. Infection Contact most likely last week of November. I had a Viral load of 1,5 Mill. at the End Of December. Started Biktarvy right away.
At the End of Jan 2022 VL had dropped to 1000. In April 2022 VL of 70. July 2022 VL of 55. It took over 2 years to get to a VL of < 20. Jan. 2024. And in my last Test VL of 31 under Biktarvy. It might just take longer in some People to achieve an Viral suppression/ Undetectable.
Hi H, it is good to hear that you are finding Biktarvy easy to take along with you not having any resistance to it.
It is also encouraging that your nutrition and exercise routine is going well.
There is one exception to not being able to attain a viral load when on the same treatment. Rarely there are cells that are in parts of the body where the treatment can’t get to. These cells then continue to replicate and maintain a low level of the viral load. In these cases it can take much longer to achieve and undetectable viral load. This is explained further here: https://i-base.info/htb/35801
Have you spoken to anyone about how your are struggling with your viral load? Would you feel comfortable talking to friends/family or your doctor about how you are feeling? I recognise that it is frustrating and can be disheartening when you are doing everything right and it still isn’t as good a result as you want. At least talking about this can help the people around you to support you as you need.
Hello again,
First of all, thank you for your response. I have no idea when I got infected, but I know that when I was diagnosed in September 2022, my viral load was 1.6 million, and my CD4 count was 275. Unfortunately, I don’t know if my start of treatment was early. My viral load tests have been happening approximately every month over the past year, and because it didn’t become undetectable, frequent viral load test checks were conducted. However, the last two tests were done with a 2.5-month interval. I had my last test done last week, and it seems my viral load has gone back up from the 400s to the 600 range.
I want to continue with Biktarvy due to its ease of use and the fact that I haven’t developed any resistance. My nutrition and exercise routine are actually progressing regularly. I even quit smoking last year after being diagnosed. However, not reaching an undetectable viral load is quite taxing psychologically. Thank you again for your response.