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Would appreciate your advice: Cameroon exposure
May 8, 2004

Dr. Sherer,

Your expertise on mutated strains/evolved subtypes of HIV is very interesting and helpful.Thank you for that.

I very much need your advice: I had a significant HIV exposure in Cameroon where many HIV subtypes/groups are prevalent. Have been very ill since then (15 months ago), with a persistently low CD4/CD8 ratio (.9) and usually very elevated CD8's. CD4 count has stayed within normal, though went down from 1,200 to 600 in five months after infection (same lab and time of lood draws) and then recovered to 1,000, before repeating essentially the same trend down and up. CD4 percent went from 46 down to 32 in the same time frame and then recovered to 40.

In addition to a low CD4/CD8 ratio and constantly elevated CD8's, I have some kind of immune suppression based on very low NK cells too. And the glands in my throat and groin constantly hurt,plus muscle weakness and diagnsoed thrush as well as angular cheilitis.

The commercially available ELISA test through Quest was negative at 1 year after this exposure, but I spoke to Quest and they said they use a test that was FDA approved in the late 1980's - this is a concern, because even if their ELISA has been modifed a bit since then, there are whole new generations of tests that have been developed since then and may be more broadly reactive to various subtypes. But Quest, while a very good lab, seems to have the lock on the testing market for most Doctors on the East Coast.

If I were your patient and you suspected a form of HIV from Cameroon that may elude the Quest test and a negative bDNA one year after exposure, what tests would you order to rule out or in HIV or another form of retrovirus? My ID doctor says my case is more complex due to exposure in Cameroon, where he says there is the highest prevalence of groups and subtypes (HTLV 1 and 2 and Hep B and C have been excluded through testing and ELISA's for Groups N and O were also negative 7 months after exposure). Would a viral co-culture make sense and have they been proven to find all subtypes? My concern there is that the sensitivity of co-cultures seems so variable, some claiming 95 percent and other saying it is 60 to 70 percent. Something is very wrong and the coincidence in timing with a high risk HIV exposure is why HIV remains on the radar.

Also, if I have antibodies to the tetanus toxoid vaccine given 2 years ago and to a Hep A vaccine, would that be complete proof that I would develop HIV antibodies measurable on an ELISA upon infection?

I would greatly value your advice on all tests that I could have done to finally resolve the HIV issue, especially since diagnostic tests here in the US seem more geared to B subtype and to some extent the majors, such as A through E...but that leaves a lot of subtypes prevalent in Cameroon.

Many thanks for your kind advice and recommendations.

Response from Dr. Sherer

It is not true that the diagnostic tests for HIV are 'geared to type-B strains', as you suggest. The current tests are equally effective for non-B strains, as we are increasingly seeing non-B strains in this country.

I agree with the tests that you and your doctor have pursued to adress this question. From what you tell me, it is unlikely that you have HIV, including a non-B strain of HIV. My first reaction would be to simply repeat the tests you have had, i.e. a current ELISA and western blot, as well as a 1.5 Roche PCR-RNA assay, and/or a bDNA, as well as tests for HTLV1 and 2. Perhaps this has already been done.

I do not profess to have special expertise in this area. If I were your physician, I would consider seeking a consultation from a virologist/clinician with expertise in the clinical syndromes and alterations in the diagnosis of non-B strains. Thus, one reasonable request for your doctor would be to obtain a consultation with such a physician. Again, it is possible that this has already taken place.

I would not suggest viral co-culture, which as you suggest is notoriously unreliable.

Your CD4 cell results are within normal limits, and there are numerous other possible explanations for abnormal immune tests such as low NK cells, to the point where they have limited clinical value.

Thrush, especially if transient, and angular cheilitis, also can occur in many settings, such as diabetes, chronic antibiotic use, nutritional deficiencies, or intestinal parasitosis, among others. I presume that you and your ID physician have explored these possibilities.

I am also impressed that the fear of HIV, brought about by a single 'high risk' exposure and its resulting guilt, can be a powerful force, and in some cases overwhelming. At this moment, in my opinion, you do not have HIV infection, and your symptoms are more likely attributable to something else.

I noted that you did not offer your doctor's final opinion on this question. I suggest that you take these comments and discuss them with him or her, and continue to try to find an answer to the cause of your symptoms.


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