My numbers... Stribild?...Gnome?

[mspButtMunch]

Got my first poz numbers today... 17000 and 450. So I guess time is on my side as to determine what my course of action is. Also the doc brought up a term I've never seen discussed before... Gnome.. Guess it has something to do with the cellular makeup of the virus. Anyone have any ideas? Also he told me about a new drug that he would recommend for me called Stribild. Anyone taking that one? Any input is greatly appreciated from my fellow pigs ! Thanks guys !

[whoai]

I think he was probably talking about the virus's genome, as in its generic makeup: http://en.wikipedia.org/wiki/Structure_and_genome_of_HIV

[layedback]

That's what my doc recommended for me. He called it the quad drug. It's a combo of several antivirals and has a drug that does something to slow down liver metabolism of the other the other drugs so they stay effective for a longer period. That's what I got out of the spiel. I think it was just approved by the FDA in the last year.

[TigerMilner]

That is referring to the particular strain of the virus you have. They always want to know that so that if you have a drug resistant strain they know that up front and you don't go thru the hit or miss approach to meds. 17K is not very high viral load but 450 is below normal for cd4 cells. It should all correct pretty quickly if you go on meds. The viral load will go to undetectable in a month or two but the cd4 cells take longer to rebuild. I do not know anything about Stribild. I'm on Complera, which is new as of last year and my viral load has remained undetectable with a few slight blips and my cd4 cells are increasing. You will be ok. d

[PhoenixGeoff]

Here's what you need to know about your two numbers:

Viral Load is a measure of how many copies of the HIV virus they find in your blood. Broadly speaking, it tells you how quickly the virus is reproducing. The higher the number, the further along your infection is. You want this number to be as low as possible; "undetectable" currently means less than 50 copies. Note that you can be undetectable for years, but you're still infected; HIV hides out in a number of places in the body, and while the HIV drugs stop it from reproducing, it doesn't actually kill the virus that's already there.

Sometimes, because the viral load can get very high (millions or even billions of copies), this number is expressed as a logarithm.

CD4 count refers to the number of CD4+ T helper cells in your blood sample. These cells are basically the mastermind of your active immune system. They are the ones that will trigger an immune response to an infection (specifically, they trigger B lymphocytes to produce antibodies--proteins that bind to and either kill viruses and bacteria or tag them for destruction and also what the HIV test looks for--and trigger CD8+ T killer cells which will destroy infected cells). Remove these cells from the picture (which is what HIV does) and your immune system will no longer respond to infections. These so-called "opportunistic infections" are what actually kills you.

Your CD4 count will naturally vary quite a bit depending on a number of factors. Age, general overall health, mood, exercise, sleep, diet, genetics...all of these things can have an impact on how healthy your immune system is and how well it will stand up to the HIV infection. Like Tiger said, 450 is a bit low, but you're still OK. In general, the CDC recommends that treatment start at the latest when your CD4 count drops to 350 or below. However, there is some research that suggests that earlier intervention is better...by starting treatment while your CD4 count is still relatively high you're setting a good baseline.

***

In general, the magic number for HIV treatment is three drugs that attack the virus in three different ways. HIV mutates extremely easily, which is why early drugs that successfully stopped HIV in the lab didn't work for very long in patients when given by themselves. What happened is that the AZT would stop the virus from reproducing for a short time, but it would mutate, become resistant to AZT and then start growing again.

The three HIV drugs in Stribild attack two of the proteins that HIV uses to reproduce. One is an integrase inhibitor, which the virus uses to transfer its genetic material into the chromosome of the cell it has invaded (it integrates it into your cellular DNA, hence the name). Stop the integrase, and the virus cannot insert itself into your DNA, which means it's blocked from reproducing (viruses reproduce by hijacking your cells and getting them to make copies of the virus rather than reproducing themselves). Integrase inhibitors are a relatively new class of drugs; they've only been on the market for the last five years or so.

The other two HIV drugs in Stribild attack a different protein called reverse transcriptase. Reverse transcriptase is a protein used by the virus to convert HIV's RNA into DNA that can then be integrated (via integrase) into the cell's own DNA. Each of the two drugs attack reverse transcriptase in different ways (there are three subclasses of reverse transcriptase inhibitors). This class is the oldest class of HIV drug; one of the drugs in Stribild is actually closely related to the very first HIV drug, AZT.

So the bottom line here is that you must have (at least) three different drugs attacking HIV in three different ways in order to control it. Any less than that, and HIV will eventually mutate and become resistant to those drugs. Worse, that resistance is inherited, meaning that those particular drugs will never work again on your virus. And even worse still, in general, if your virus acquires resistance to one drug, then it acquires resistance to all other drugs in the same class.

So a lot of HIV research has focused on two areas: first, developing medications within existing classes that are easier to take (may be taken fewer times per day, fewer side effects, etc.); second, developing new classes of medications that attack HIV in new ways (like integrase inhibitors vs. the three kinds of reverse transcriptase inhibitors; in addition, there are other classes that your doctor is holding in reserve for you, like protease inhibitors, fusion inhibitors, etc.). Having a wide range of medications in each class, and a wide range of classes increases the arsenal we can throw at the virus. The wide range of medications within a class means we can look for a medication that will be easy for you to take. And lots of classes means that we have fallback positions should you acquire resistance to one or more of your meds.

Over time, we've identified certain combinations that work particularly well for many people. The drug companies have conveniently bundled these into single pill formulations to make things even easier for you. These are once-a-day regimens that have few side effects for most people. Stribild is one example; Atripla and Complera are others.

***

So what should you be doing?

Your part in your therapy is twofold: 1) prevent resistance and viral mutation. 2) maintain your immune system

The most important thing you can do is prevent HIV from becoming resistant to your drug regimen. You do this by taking your medications as prescribed consistently. Skipping doses allows the virus to start growing again. This in turn gives the virus a chance to gain resistance to the drugs you have been taking.

Ask your doctor questions. What side effects can I expect? Will they get better with time? Are there any life-threatening side effects? When should I take the drug? Should it be taken with food or without or does it matter?

Monitor your side effects. If they are difficult to live with, do not stop taking the drug (unless it's a life threatening side effect; then go to the hospital immediately). Report the side effect to your doctor. He or she will work with you if they are causing you serious problems. This generally means finding a different drug that may be easier for you to take. Remember, you're looking for a drug combination that will work for you indefinitely; I've been going strong on mine for about ten years now.

Don't try to tough it out. I made this mistake early on. I didn't report some pretty difficult side effects, figuring that I could handle it. I couldn't, ended up skipping doses, and now I'm resistant to two medications.

Remember, keeping your meds with you requires some advance planning. If you will be traveling, bring everything you need plus some extra. You should never be without at least a one month supply unopened. You should never be caught in any situation where you might run out of your meds.

As for maintaining your immune system, this is all of the good advice doctors give us that we never take.

• Eat a healthy diet, including lots of fruits and vegetables
  
• Get eight hours of uninterrupted sleep every night
  
• Exercise regularly
  
• Avoid recreational drugs, including alcohol and tobacco (many actively disrupt the immune system)
  
• Maintain good, positive mental health; seek help if necessary
  

[HungLatinDom]

Man, that's a very, very helpful post. Thank you so much for putting time and effort on this.

One of the reasons why I love this forum.

Here's what you need to know about your two numbers:

Viral Load is a measure of how many copies of the HIV virus they find in your blood. Broadly speaking, it tells you how quickly the virus is reproducing. The higher the number, the further along your infection is. You want this number to be as low as possible; "undetectable" currently means less than 50 copies. Note that you can be undetectable for years, but you're still infected; HIV hides out in a number of places in the body, and while the HIV drugs stop it from reproducing, it doesn't actually kill the virus that's already there.

Sometimes, because the viral load can get very high (millions or even billions of copies), this number is expressed as a logarithm.

CD4 count refers to the number of CD4+ T helper cells in your blood sample. These cells are basically the mastermind of your active immune system. They are the ones that will trigger an immune response to an infection (specifically, they trigger B lymphocytes to produce antibodies--proteins that bind to and either kill viruses and bacteria or tag them for destruction and also what the HIV test looks for--and trigger CD8+ T killer cells which will destroy infected cells). Remove these cells from the picture (which is what HIV does) and your immune system will no longer respond to infections. These so-called "opportunistic infections" are what actually kills you.

Your CD4 count will naturally vary quite a bit depending on a number of factors. Age, general overall health, mood, exercise, sleep, diet, genetics...all of these things can have an impact on how healthy your immune system is and how well it will stand up to the HIV infection. Like Tiger said, 450 is a bit low, but you're still OK. In general, the CDC recommends that treatment start at the latest when your CD4 count drops to 350 or below. However, there is some research that suggests that earlier intervention is better...by starting treatment while your CD4 count is still relatively high you're setting a good baseline.

***

In general, the magic number for HIV treatment is three drugs that attack the virus in three different ways. HIV mutates extremely easily, which is why early drugs that successfully stopped HIV in the lab didn't work for very long in patients when given by themselves. What happened is that the AZT would stop the virus from reproducing for a short time, but it would mutate, become resistant to AZT and then start growing again.

The three HIV drugs in Stribild attack two of the proteins that HIV uses to reproduce. One is an integrase inhibitor, which the virus uses to transfer its genetic material into the chromosome of the cell it has invaded (it integrates it into your cellular DNA, hence the name). Stop the integrase, and the virus cannot insert itself into your DNA, which means it's blocked from reproducing (viruses reproduce by hijacking your cells and getting them to make copies of the virus rather than reproducing themselves). Integrase inhibitors are a relatively new class of drugs; they've only been on the market for the last five years or so.

The other two HIV drugs in Stribild attack a different protein called reverse transcriptase. Reverse transcriptase is a protein used by the virus to convert HIV's RNA into DNA that can then be integrated (via integrase) into the cell's own DNA. Each of the two drugs attack reverse transcriptase in different ways (there are three subclasses of reverse transcriptase inhibitors). This class is the oldest class of HIV drug; one of the drugs in Stribild is actually closely related to the very first HIV drug, AZT.

So the bottom line here is that you must have (at least) three different drugs attacking HIV in three different ways in order to control it. Any less than that, and HIV will eventually mutate and become resistant to those drugs. Worse, that resistance is inherited, meaning that those particular drugs will never work again on your virus. And even worse still, in general, if your virus acquires resistance to one drug, then it acquires resistance to all other drugs in the same class.

So a lot of HIV research has focused on two areas: first, developing medications within existing classes that are easier to take (may be taken fewer times per day, fewer side effects, etc.); second, developing new classes of medications that attack HIV in new ways (like integrase inhibitors vs. the three kinds of reverse transcriptase inhibitors; in addition, there are other classes that your doctor is holding in reserve for you, like protease inhibitors, fusion inhibitors, etc.). Having a wide range of medications in each class, and a wide range of classes increases the arsenal we can throw at the virus. The wide range of medications within a class means we can look for a medication that will be easy for you to take. And lots of classes means that we have fallback positions should you acquire resistance to one or more of your meds.

Over time, we've identified certain combinations that work particularly well for many people. The drug companies have conveniently bundled these into single pill formulations to make things even easier for you. These are once-a-day regimens that have few side effects for most people. Stribild is one example; Atripla and Complera are others.

***

So what should you be doing?

Your part in your therapy is twofold: 1) prevent resistance and viral mutation. 2) maintain your immune system

The most important thing you can do is prevent HIV from becoming resistant to your drug regimen. You do this by taking your medications as prescribed consistently. Skipping doses allows the virus to start growing again. This in turn gives the virus a chance to gain resistance to the drugs you have been taking.

Ask your doctor questions. What side effects can I expect? Will they get better with time? Are there any life-threatening side effects? When should I take the drug? Should it be taken with food or without or does it matter?

Monitor your side effects. If they are difficult to live with, do not stop taking the drug (unless it's a life threatening side effect; then go to the hospital immediately). Report the side effect to your doctor. He or she will work with you if they are causing you serious problems. This generally means finding a different drug that may be easier for you to take. Remember, you're looking for a drug combination that will work for you indefinitely; I've been going strong on mine for about ten years now.

Don't try to tough it out. I made this mistake early on. I didn't report some pretty difficult side effects, figuring that I could handle it. I couldn't, ended up skipping doses, and now I'm resistant to two medications.

Remember, keeping your meds with you requires some advance planning. If you will be traveling, bring everything you need plus some extra. You should never be without at least a one month supply unopened. You should never be caught in any situation where you might run out of your meds.

As for maintaining your immune system, this is all of the good advice doctors give us that we never take.

• Eat a healthy diet, including lots of fruits and vegetables
  
• Get eight hours of uninterrupted sleep every night
  
• Exercise regularly
  
• Avoid recreational drugs, including alcohol and tobacco (many actively disrupt the immune system)
  
• Maintain good, positive mental health; seek help if necessary
  

[PhoenixGeoff]

Man, that's a very, very helpful post. Thank you so much for putting time and effort on this.

One of the reasons why I love this forum.

Thanks HLD....facing HIV can be a scary proposition. I found the best way for me to handle it was to learn as much as I could about it. I guess the idea is if I can wrap my head around it, I can beat it. As you can tell, I'm a bit of an over-intellectualizing and analytical type LOL.

But the nice part about all that is that I can distill that knowledge for other people, which they'll hopefully find useful.

[HungLatinDom]

Thanks HLD....facing HIV can be a scary proposition. I found the best way for me to handle it was to learn as much as I could about it. I guess the idea is if I can wrap my head around it, I can beat it. As you can tell, I'm a bit of an over-intellectualizing and analytical type LOL.

Exactly my position. I was very happy about being a biologist when I got infected. It gave me calm and a sense of control.

[bearbandit]

Excellent post MMM, but could I add a little to it? Of the components of Stribild, elvitegravir is new (same class as raltegravir, which I'm finding to be pretty trouble free). Cobicistat is a new booster drug, eventually intended, I believe to replace ritonovir. Emtricitabine is a close relative of 3TC which was available in the mid nineties - 3TC was originally only available to people who were on the nevirapine trial, which is how I encountered it and tenofovir is, in my opinion, due for retirement.

Tenofovir can cause permanent kidney damage - I've gone from throwing around a 600cc city bike on country roads to needing a walking stick in eighteen months (they tell me that my broken ankle might never heal), as well as needing numerous mineral and vitamin supplements. It's no fun cleaning the limescale off a PA every other week! If someone goes for this drug it's essential that their kidney function be monitored on a regular (every 3 months would be my best guess). If things go wrong, the convenience of on drugs could be replaced by taking twelve drugs a day.

In the UK we're seeing no real gender difference between people having adverse reactions to tenofovir, even though in later life osteopenia and osteoporosis tend to affect women more than men. Onset of adverse affects seems to come between three and six years of starting tenofovir. Because tenofovir is a component of truvada, the other component (FTC) tends to get the blame too, but it's definitely tenofovir. So I'd say to anyone taking stribild (or tenofovir) that they should have several full kidney work-ups per year. Tenofovir's side effects also hurt, and not in a good way.