This issue’s specialists:
Amy Sitapati, M.D., AAHIVS
and Joseph Caperna, M.D., MPH, AAHIVS

Dear HIV Specialist,

I am a 64-year-old male, diagnosed with HIV in 2006, and began taking Truvada and Kaletra (4 once daily). My viral load fell from 362,000 to undetectable by early 2007 and remained undetectable until my last blood test in January this year. My doctor said it may be a blip, or the virus may have become resistant to the medication. I am scheduled for another blood test in early June, but the wait is making me very anxious. The last viral load reading was 108. My blood work for all other areas tested has been excellent, including cholesterol, PSA, liver and so on. My blood pressure is generally 115/72 or lower. I never miss my medication. If the virus has become resistant to the current medication, what are my options for other medication?

Signed,
Resistance or Blips?

Submit your questions for Ask The HIV Specialist to AAHIVM@tpan.com

Dear ROB,We agree with your doctor. One does not know at this point [when the letter was received in February 2009] if this small increase in viral load was a “blip” or if the virus has become resistant.
If your virus has developed drug resistance, that is a topic for another column. We would need to see the results of a resistance test and the interpretation of resistance test results remains complicated.

It is also important to know whether there is any new medical history, such as recent surgery, illness, or vaccination (these can increase viral load more than a blip, or greater than 200 copies/ml). A physician should assess you for new medications or herbs which might interact with the antivirals. Finally, we assume you are taking all doses of your medications. Intermittent “adherence” or not taking 100% of the doses, can lead to blips.

“Blips” are a common concern in the field of HIV. There are several ways to look at an increased viral load. Depending on which type of machine was used to measure the HIV viral load, the amount of virus used to classify undetectable will vary. A “blip” is a viral load increased to 200 (some authors use 400) copies/ml, slightly increased, but not completely undetectable.

Historically, blips were discussed in 2000 or before, and at first were thought to predict future virologic failure, or that sometime in the future the viral load would increase dramatically. Using actual numbers, one example is a patient with less than 50 for years who has a new viral load of 188. It is uncertain whether or not this would mean the viral load might increase significantly (such as up to 3 logs or 188,000) in the near future. At the Durban International AIDS Conference in 2000, Dr. Diane Havlir presented a study of patients on indinavir [Crixivan] with prior long-term control of less than 50. Blips in this group did not predict future virologic failure. In contrast, Wensing et al, at the same conference, presented data on patients on different regimens. The Wensing study showed blips were associated with future greater increases in viral load.
Again, a single blip does not mean virologic failure. In fact, the DHHS “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” (Nov. 2008) define virologic failure as “a confirmed HIV RNA level of greater than 400 copies/ml after 24 weeks, greater than 50 copies/ml after 48 weeks, or a repeated detectable HIV RNA level after prior suppression of viremia [viral load].”

The definition of “blip” may change as newer assays (tests) are developed that detect down to incredible levels, such as less than 1 copy/ml, and the new ability to see if patients with less than 50 have less than 1 or somewhere between 1–50, and what that might mean. We previously did not have this ability, and we are in transition with these more sensitive assays. Finally, as we look to the future, and the empowerment of patients, we hear of technology being developed that will allow patients to monitor their viral loads from home. Visit TheBody.com for excellent information on blips. 

Amy Sitapati, M.D., AAHIVS
Associate Director, Owen Clinic
University of California, San Diego

Joseph Caperna, M.D., MPH, AAHIVS
Clinical Physician, Owen Clinic
University of California, San Diego

Is your provider an AAHIVM-credentialed HIV Specialist™?

If you are living with HIV, you have a lot of choices to make when seeking care and treatment. One of your most important choices is your health care practitioner—so why not choose someone who is knowledgeable about HIV and experienced in its treatment?

The American Academy of HIV Medicine (AAHIVM)’s HIV Specialist™ credentialing program is the first and only clinical credentialing program offered domestically and internationally to physicians (MDs and DOs), nurse practioners and physician assistants specializing in HIV care. HIV care providers become designated HIV Specialists™ after meeting experience and education requirements, and successfully completing a rigorous exam on HIV-specialized care. Look for the letters “AAHIVS” after their name.

Locate an HIV Specialist™

Your search for an HIV Specialist™ is easy with AAHIVM’s online Find-A-Provider directory at www.aahivm.org. Just click on the “Find-A-Provider” window on the homepage, key in your location and click on the search button for a list of HIV Specialists™ near you.

Due to space limitations, not all submitted questions can be answered in this column, but every effort is made to ensure you receive the information you have requested. For more information about AAHIVM, call 202-659-0699 or visit www.aahivm.org.

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