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.
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Joshua Rohr
Seattle WA
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Original Message:
Sent: 05-10-2022 19:41
From: Benjamin Sokoloff
Subject: Persistent Viremia
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?
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Ben Sokoloff, DO
Cascade AIDS Project
Portland, OR
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