Role of HIV-1 Viral Load in Initiating Antiretroviral Therapy153
of the patient had genotypic resistance to at least one
reverse transcriptase inhibitor (RTI) or protease inhibitor
(PI) [16]. In Surveillance on HIV antiretroviral drug re-
sistance in treated individuals in England HIV drug re-
sistance reported was 55% [17].
Hence, for rationale use of ART, viral load can be a
better guide compared to CD4 alone. When viral load
and CD4 count both are used for predicting progression
to AIDS better estimate of risk of progression is provided
compared to when either marker is used alone [18]. Also
if baseline viral load is available one can monitor the
response to treatment by documenting the fall or rise in
viral load [11].
Viral load monitoring is significantly superior to CD4
monitoring in assessing viral suppression and treatment
failure in patients on ART [9,10] and as clinical failure is
an even later development, defining treatment failure on
clinical grounds alone is equally suboptimal [1].
Hence, under the National AIDS Control Programme
(NACP), the State Reference Laboratories (SRL) can be
given the responsibility of performing baseline viral load
estimation and monitoring response to therapy especially
in case of suspected drug resistance.
In the present study, eight out of 38 females and two
out of 58 males had viral load <5000 copies/ml.
In a meta-analysis for gender difference in viral load,
Sonia Napravnik et al. (2010) observed that a given
population of women have, on average, lower plasma
HIV RNA levels compared with a population of men
with similar CD4 lymphocyte counts and stage of HIV
disease [19]. Shade SB et al. (2000) also observed similar
gender differences in viral load. Women with advanced
HIV disease have slightly lower levels of viral load than
men at corresponding levels of CD4+ cell counts [20].
These gender differences in viral load could necessi-
tate gender specific recommendations for initiation of
ART. Hence when HIV-1 RNA thresholds are used to
form treatment recommendations for initiating ART, a
lower threshold is likely indicated for women compared
with men.
To conclude, decision to start patient on ART can be
made judiciously when viral load is used along with CD4
count estimation. Also, if baseline viral load value is
available it will help in assessing subsequent response to
therapy once initiated. Gender differences in viral load
necessitate gender specific recommendations for initia-
tion of ART. Virological monitoring should be combined
with clinical and immunological monitoring for better
patient management.
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