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  • 1.  Persistent Viremia

    Posted 05-10-2022 19:41
    Hello to the community, 

    I'm asking for input about one of my patients with persistent viremia and who was diagnosed with HIV in May 2021 during hospitalization for presumptive PJP and esophageal thrush. His initial viral load was 770k and seemed to have come down nicely while on Tivicay and Descvoy to 480 in June 2021 (no other ART exposure). There were no RAM's on his initial genotype and it is unknown if that was drawn before or after he was started on ART. I changed him to Biktarvy at that time in June to simplify the regimen. His initial CD4 absolute was 134 and since June 2021 has maintained over 260 and with a percentage now 17. Since then his viral load has fluctuated to 149 in October, 286 in March, and 65 this month. He is adamant regarding perfect adherence to Biktarvy. There is no other medical history of concern, no other prescribed meds, he denies taking any vitamins/supplements or anything for heartburn, no substance use or significant mental health history, and he is housed. He hasn't had a viral load high enough to successfully run a genotype. For now I am monitoring and probably will keep to q3 month intervals. Although most likely his adherence is not as perfect as he describes, my concern is that he is at risk for developing resistance if he has not already.

    Would any of you do anything additional beyond close monitoring such as adding a 4th agent or archived genotyping?

    Ben Sokoloff, DO
    Cascade AIDS Project
    Portland, OR

  • 2.  RE: Persistent Viremia

    Posted 05-11-2022 15:14
    It does sound like your paiient is doing everything he is supposed to. I would probably do what you are doing too by keeping him on short interval follow-up but I would bring him back in for the archive genotype now.

    Cara Grove, MSN, APRN, FNP-BC
    Christiana Care Holloway Community Program
    Georgetown, Delaware

  • 3.  RE: Persistent Viremia

    Posted 05-11-2022 15:31
    This looks good to me! I would not be concerned about resistance at all with a declining viral load. 65 is almost undetectable and it's possible that now he is down under 200 copies, he's releasing small amounts of non replicating virus from his latent reservoirs. There are specific guidelines for monitoring every 6 months, and this patient doesn't fit the bill based on CD4 alone so cont q3m and stay the course!

    Angela Kapalko
    Physician Assistant Chairperson for AAHIVM
    Philadelphia FIGHT CommunityHealth Centers
    Philadelphia PA

  • 4.  RE: Persistent Viremia

    Posted 05-11-2022 15:54
    Dear Ben,
    Perhaps check with him if he is taking any OTC products that contain divalent or trivalent cations (Ca++, Mg++, Fe2+/3+, Al+++), like antacids or mineral supplements which can interfere with InSTI absorption.
    W. David Hardy, MD
    Scientific and Medical Consultant
    310-709-3505 (Mobile)

  • 5.  RE: Persistent Viremia

    Posted 05-11-2022 22:37
    First have himher bring his pill bottles every visit so you can count pills and see if he has “extra pills”.
    Watch himher set an alarm on their cell phone for the time they take their pill.
    I ordered about a dozen archive geno tests and never found any hidden mutations, so I rarely do that anymore.
    I think rukobia and doravirine are decent 4th drugs as well if you decide to try that.

    Sent from my iPad

  • 6.  RE: Persistent Viremia

    Posted 05-12-2022 15:22

    Lots of good responses already.  In these cases and especially with Biktarvy I still find low level viremia usually comes down to adherence or interactions. Maybe another round of asking about OTCs-taking any creatine, muscle gainers, energy drinks, turmeric and so on?

    For adherence, see if you can look at the dispense dates at the pharmacy to see if he's filling on time.  Offer a pill organizer to hopefully highlight to patient if he indeed has been missing doses, set a daily phone alarm.

    Is partner also on Biktarvy, could there be pill sharing? 

    Any GI issues that would impact absorption? 

    Good luck. 

    Joshua Rohr
    Seattle WA

  • 7.  RE: Persistent Viremia

    Posted 05-13-2022 15:16
    BIktarvy would be an appropriate choice.

    Gwen Verlinghieri
    AIDS Care Group
    Chester, PA