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HIV - HBV Question
Oct 22, 2007

I was recently infected with HIV and subsequent tests have also determined I have HBV. I was diagnosed during the HIV acute phase, with what the doctor said was the typical mononucleosis style symptoms I had. At that time the HBV testing had not come back, as I was going in for tests and diagnosis of this yet to be determined illness . When the tests came back I was sero-negative for HIV (no antibody) but had a viral load of over 1M copies. The HBV test came back positive a week later. My doctor, or should I now say doctors (of which I have two and possible third in the future (HIV-ID, PCP - primary care, and a Liver specialist, which I have not seen yet), are at George Washington Medical Facility Associates in Washington, DC. I hear its a great facility with excellent doctors so I am happy about that. The question I have first one - I was diagnosed during the acute phase (at about 2 weeks while I was still feeling ill) and it was recommended that I start HAART immediately. This surprise me as you mostly read that people wait until CD4 T-cells go down under 350, which can be many years. My doctor said that due to recent studies that it would be best, if I could tolerate the HAART, that I start immediately, even before genome resistance testing. I agreed and started Atripla immediately. A 3 weeks later the resistance testing came back that the virus I have is resistant to SUSTIVA (which I hated anyway made me quite dizzy and tired) so I was switched immediately to Reyataz with the Norvir booster and Truvada. I feel find and am not dizzy anymore. My question is this normal. So much literature I read online indicates that this early treatment is very new. Ive managed to find a couple that indicate less immune cell loss in the intestinal area but cant find too many people doing this. My viral load was down from 1M to 18000 in three weeks on the resistant atripla (the test was taken just before I stopped it). Ive now been on the PIs for three weeks and am awaiting the test result this or next week. CD4 count was 697 at the three week (Atripla stopping point). Again the new CD4 tests should be in soon for the 3 weeks Ive now been on the PIs (Reyataz, Norvir boster, Truvada) once per day. The doctors say I am doing very well at this point. Im 39 year old male. Your thoughts on this? My next question is about the HBV. I know there are lots of tests and I dont have that much info, but I was told its not cleared (positive hb something). The puzzling thing is the two tests have come back undetectable for the HBV viral load. The first one was taken around the time I started the Atripla (the same day so it could not have had an effect) and the second one a few weeks later, when I taken Aptripla for three weeks and then had to switch to the PIs. They are taking a third test which I should find out next week, having been on the PIs now for 3 weeks. The HIV and PCP were puzzled at the test results all liver functions came back normal (I dont have the reports yet) and yet they said I was chronic according to the chart (I saw the chart where you look up your values of each HBV tests to determine what stage you are in) so I assume its that one. Both doctors said they were puzzled and needed to do more research and contact a liver specialist, not necessarily for treatment (as I was told I didnt need to make an appointment to see this liver doctor), but to understand why this is. The doctors said it was very good (the only thing being better is perhaps a test of the HBV cleared with no viral load or perhaps never getting it in the first place) Any thoughts on this one?

Response from Dr. McGovern

For your HIV question I refer you to the HIV forum for further information. I should make clear that yes you are right that in chronic infection, treatment is started when CD4 cells are less than 350. However, in acute (new) infection, there is some evidence suggesting that there may be benefit to starting early. You were diagnosed earlier than most people - in the setting of no positive antibody - only virus. It is unclear at present whether patients benefit from early treatment or not. I usually like to enroll patients like you in a study of early treatment so that we can understand the answer to this question. However, if I didn't have access to such a study, I probably would have started you on therapy as well due to your symptoms, high viral load, and very early diagnosis (no reactive antibody).

As for your HBV question, this is harder to answer because I don't have your lab results. However I suspect they may have been puzzled by the fact that your serologies are consistent with new acute HBV infection, yet your HBV virus test is non detectable. This could be due to "viral interference". Your HIV virus load was so high (one million) that the HBV viral load was inhibited. Another possibility is that you have laboratories consistent with an active chronic infection, but you do not have virus - this would be consistent with a "carrier" state. These explanations are only conjecture on my part since I don't have your laboratories.

Continue to take your medications with excellent adherence and you should do extremely well.



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