A colleague pointed out that what you describe is not really "low-level viremia," the term I used, and she is correct. This does not meet the standard definition for low-level viremia. It's delayed suppression, and maybe we could call it "viremia at a low level," which sounds almost the same, but isn't.
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Joel Gallant, MD, MPH
Santa Fe, NM
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Original Message:
Sent: 09-14-2024 17:46
From: Joel Gallant
Subject: Slow to suppression
While this is unusual, I wouldn't be too concerned about resistance, which is virtually never seen in treatment-naive patients on this regimen if they have no baseline resistance. I would do what we usually do in cases of low-level viremia: ask about adherence and the use of any concomitant supplements or antacids that could decrease bictegravir absorption. I would follow closely, but don't see the need for intensification at this point.
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Joel Gallant, MD, MPH
Santa Fe, NM
Original Message:
Sent: 09-13-2024 15:24
From: Marc LaRiviere
Subject: Slow to suppression
Normally viral suppression occurs within 3-4 months, seems to be taking a while and I share your concern with the viral load more than 200 7 months out.
The most problematic patients for long-term viral suppression are those with advanced disease and very high viral loads, like your man.
For new patients with a viral load a million or more I start them initially on Biktarvy and Prezcobix for the first 3 months, then drop the Prezcobix and continue Biktarvy – the idea being hoping to limit resistance.
For this patient, besides the idea already put forth of adding LEN you could add Prezcobix to the Biktarvy for 3 months and see what happens – if he suppresses continue the combo.
Marc LaRiviere
Los Angeles, California
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Original Message:
Sent: 9/13/2024 1:24:00 PM
From: Barbara Hart
Subject: Slow to suppression
Hello all,
I am still pretty new to this and have a question about viral suppression. I have a fellow diagnosed with advanced HIV in Feb 2024 with CD4 count 41 on 2/7/24. HIV viral load 3,674,999. Treated with Bactrim for pneumonia in the ED. CMV viral load was 294. Also treated for chlamydia and gonorrhea with resolution. He was on JAK inhibitor Deucravacitinib for psoriasis at the time of his diagnosis but has been off this since February.
He has been taking Biktarvy consistently but has not reached full viral suppression. Most recent VL was 864 on 9/6/24. CD4 165. Takes atovaquone for OI prophylaxis.
He had Genosure and Phenosense in June with no drug resistance reported. Is this just a slow response? Is there anything to add or change in his treatment? I would be very grateful for any recommendations. Thank you.
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Barbara Hart
Lawrence KS
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