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HusbandHIV+ and WifeHIV-
Aug 24, 2002

Dear Dr. Benjamim, I am heterossexual, 38 years old, married since 1997. In 1996, before to get married, I got Elisa blood test and the result was negative. During 5 years, We have a intensive sexual life as a couple, with oral, anal and vaginal sex practices. Sometimes with condom to avoid pregnancy, sometimes without.

This month we decided to have a baby. I am enginneer, I like to plan everything, and I looked for all types of tests for a previous mother and father. My wife tested negative by antibody test ELISA. About my future daddy tests, I just recently found out I am positive with HIV (ELISA). The Lab called me to take another sample for blood test WESTERN-BLOT, and the results are intensive bands ++ in GP160, GP120, P66, P55, P51, GP41, P31, P24, P17, positive again at the same Lab. I am very confused, because I am very responsible to avoid sexual contact with another persons, for instance, I don't drink to avoid forget the responsabilities, there is no chance. My relation with my wife is perfect in psycological, emotional and behavioral, there is a lot of understanding to avoid lies between us. On the other hand, I never take blood transfussion, and I choose my best friend(school) as our dentist to avoid risk of blood contact and get HIV infection. After this results, my doctor decide to confirm the results in anothers Labs. We choose two differents Labs. My doctor decided include another tests for hepatitis B, C, shyphilis, T4 (CD3+/CD4+), T8 (CD3+/CD8+), virus load, VDRL, CMV, ... too. At this moment, two labs called me to take another sample for antibody tests. About shylphilis test, I am negative in VDRL. My T4 (CD3+/CD4+) is 229/mcl or 17,9. My T8(CD3+/CD8+) is 910/mcl or 71,2. After this results, the evidence show I have HIV+. Probably, I can say the train is near to AIDS (T4- 200). I don't know the viral load now, the velocity. Doctor Benjamim , I am trying to understand what happen and the next steps. My T4 is very low and I have no symptons. Based in this number, How long I was infected? Probably was I infeccted ten years ago? If it's true, what about my Elisa test done in 1996? I am a healthy person, I can remember a simple cold. I have no show "Acute Viral Syndrome". In several years, only last month I had a flu (body aches, high fever over 39 celcius degree, fatigue but no headaches, etc). I was in bussiness travel and have no time to remains on the bed, I took medicines for influenza virus, after two days , I was without symptons.

Only two months ago I had diarrhea during 15 days. After this my excrements are solid and normal.

Doctor Benjamim, please I am lost now. Ours dreams was broken, and I am afraid about my wife. I have no chance to start treatment with T4 high or after infection, I only discover now. What kind of treatment you recommend? And why you not belong to group wich choose start treatment in 200 T4? God will bless us and my wife will be remain imune. Last month she retains the semen inside to become pregnant. Her negative test was done in June, 15. We avoid sexual contact since August, 1. Tell me what we can do know. How long she need wait to make anothers tests. Will you advice T4 and T8 count, virus load, to antecipated the antibody results and start the treatment? Please comment the probability, I think we area a couple with two faces of low probability chances in both cases. My wife have 37 years old. Thanks for your attention and God bless you!!

Response from Dr. Young

Sorry to hear about your situation.

I think that we can say without any doubt that you have established HIV infection; your CD4 cell count would suggest infection that occurred at least three (maybe several more) years ago (if you have an average viral load). The negative test in 1996 would time the infection to sometime after this period; again consistent with your current CD4 count, but this is a crude estimate.

Your prognosis should be very good-- with a couple of caveats. It is clear that you should begin to consider starting on antiretroviral therapies. Which ones to take would require a detailed discussion, and definately one that you should have with your healthcare provider. There are a number of approaches, though recent data provide strong support for using dual nucleosides (either ZDV/3TC, abacavir/3TC or tenofovir/3TC, but not d4T/ddI) with either efavirenz (Sustiva) or a boosted protease inhibitor (like Kaletra). If your viral load is below 100,000, a simple triple nucleoside regimen (Trizivir) is well worth considering, particularly because of it's side effect profile and ease of administration. I'd also look to find a doctor with significant HIV experience, as this has been shown in study after study to correlate with improved response to therapy and lower complication rates.

I am not in the camp that favors deferring therapy until CD4 counts are below 200 because of several issues. The issue of delayed therapy stems from the possibility of drug-induced complications-- there is good evidence that improved adherence plays a role in prevention of side effects, so, if we can work on methods to improve adherence, certain complication rates should be lower. One of the major issues related to so-called premature starting of therapy is the risk of developing drug resistance- a serious issue, indeed. Again, efforts to improve adherence and improved potency of medications should offset this risk. Lastly, and most importantly, is are concerns about what happens to the immune system with delaying the intiation of therapy from CD4 levels between 350 and 200-- there is concern that there is continuous loss of certain aspects of immune function, some of which is not restored after immune reconstitution-- perhaps evidence of this are several studies which implicate that the risk of developing lipoatrophy (one of the symptoms of lipodystrophy) are related not to one's current CD4 count, but rather the lowest ever CD4 count. If correct, then by waiting to start to levels below 200 cells, that we may be inadvertantly increasing the risk of developing lipodystrophy. Additionally, the risk of other complications, like neuropathy and anemia also increase with lowest ever CD4 counts.

Taken together, I'd want to be sure that your clinical, social and emotional situation is the best possible before starting- this might mean deferring initiation until later times. But-- if your understanding about the how's and why's and adherence can be optimized; particulary if your viral load is average or above average (>35,000), then starting therapy with CD4 counts around 350 (or even higher) is not unreasonable.

Good luck. Stay in touch. -BY



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