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recent sero conversion and when to begin treatment
Jun 18, 2005

I had a negative HIV test April 18th, followed by a positive test May 5th which was confirmed by Western Blot. I was very ill for 5 days when I had the first test with flu like symptoms, sore throat, and swollen glands but no fever. My doctor thinks I may have sero-converted between the two tests and that I was possibly only infected shortly before the negative April 18th test. I had the 2nd test because I had developed dry itchy skin with tiny red bumps the first week of April which first was thought to be folliculitis but did not respond to treatment. The only opportunities to contract HIV would have been March 31st or January 3rd, however, I was under the impression I had "safer sex" on March 31st, but not, unfortunately, on January 3rd. I began treatment on May 12th at the recommendation of my doctor with the belief I will be better off in the long term by starting meds soon after sero-conversion. I take Combivir twice a day and Sustiva once a day. My blood was drawn on May 12th, before I began treatment, and I received the results today, May 23rd. My initial CD4 count is 482 and my viral load is 107,000. Based on this informatin what is your opinion on whether I recently sero-converted? Do you think treatment was appropriate at this time before the lab results? (My doctor seemed suprised my viral load was not higher, and is seeking another opinion) If you think treatment is premature, is it inadvisable to stop now due to possible future drug resistance? My next blood draw to verify CD4 and VL is scheduled for June 13th.

Thank you

Response from Dr. Sherer

It's not possible to estimate the duration of infection from the level of the viral load and CD4 cell count. Usually the viral load values are quite high with a recent infection (often one million or more), but the range is fairly wide, and your level would not eliminate the possibility of a recent infection.

The fact that your antibody test went from negative to positive in that short interval also doesn't definitely imply an infection in the past 1-3 months, as it can take 6-12 months for an antibody test to become positive in a minority of cases (<5%).

There is no definitive answer to the question of whether a patient with a recent seroconversion should be treated with ART. Your case differs, in that you did have symptoms, i.e. the rash. One of the few ways to effectively contol this type of rash is with ART. I suspect that this may have motivated your doctor to recommend that your start ART.

One common mistake to be avoided with ART is frequent changes in the regimen, or frequent starts and stops. I would advise that you not make a change at this point, and await your next lab tests and review your status at that time with your doctor.

Note that the current HHS Guidelines suggest that ART be considered when the CD4 cell count is below 350 cells/ml, or the viral load is above 100, it is reasonable to be considering ART in your case, both on the basis of symptoms, and on the basis of the viral load. You are in one of the difficult grey zones in which you and your doctor might reasonably choose either to continue ART, or to stop it and observe.

If you did choose to stop ART and observe at your next visit, it would be important to note whether or not the rash recurs, how severe it is if it does recur, and whether other symptoms also occur.

Another consideration that you have not mentioned is whether or not your are having significant side effects to the regimen.

And finally, it is common practice in major urban areas of the US to obtain a genotype before ART is begun to ensure that you did not acquire a virus with resistance mutations. Did you have a resistance test done? It would be an important question to ask your doctor, as the results might influence this decision as well.

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