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Acute HIV, Diahrre & Medication; Medical reasons for early testing?; Acute HIV treatment??
Jul 3, 2006

Dear Dr Bob,

first of all let me thank you SO MUCH for running this fantastic site, and for providing such a positive inspiration for coping with HIV. Now several questions

(please answer, altho by comparison with some of the qus asked here, these are low priority, I'm alone in a (very) foreign country, have no one really to talk to about these matters, and hence Worry! I'll try to design the qus so answers may be as short as possible).

The Facts: A little over 2 weeks ago I had a sexual encounter with a very nice strange lady, featuring protected vaginal intercourse (i penetrated), & unprotected oral sex and being masturbated (in both cases I received). Even tho my penis shaft was somewhat sore, red and thus quite possibly lesious, and tho she might have had vaginal fluids on her fingers, I understand this counts as a minimal to non-existant risk (?).

16 days later I have had no real complications except, 8 or so days ago, a day or so of exhaustion and light headaches, almost certainly attributable to very hot weather & smog (conditions that have always affected me badly), and yesterday night a bout of very bad diahrre, which could well be attributable to me single-mindedly provoking my stomach beforehand (tho similar provocations have drawn no such strong diahrre in the past. a bit of softness was all). I have Not run a temperature, body temp has never been above c. 36.8C, and usually lower (35.8 to 36.6ish).

QUS 1) is my above risk assessment (minimal to non-existent) accurate?

2) I'm considering taking Perenterol (basically tablets of stomach bacteria) for the diahrre. However, the packet warns not to take them if I'm otherwise ill or my imune sys is down, due to risks of the bacteria colonising more of me than just my stomach. Considering the low probability of my having contracted HIV and suffering some degree of Acute HIV, do you think it is advidable to Not take the pills?

3) Only a post-3 month test can give certainty. I'll be back in the West in 4 months, and am planning to only test then, as the country I'm in takes a very dim view of HIV+foreigners (deportation, no further entry visas etc.). Is there any medical reason why it might be advisable to test earlier (post-3 or 6 weeks)? An ancient Answer of yours Re: Acute HIV (pasted from an authoritative txtbook) commented that "many authorities" consider the outbreak of Acute HIV to be the prime time to begin treatment. If this is so (?) might it be advisable to try to get a 3 or 6 week test, and potentially return home early to undergo some treatment? (something I'd like to avoid, as it would really mess up my research work).

Again, PLEASE answer, being alone, far away and worried is not very pleasant. Irrespective of whether you manage to answer or not, I will make a meaningful donation to your excellent ngo.

Thanks a lot! Nick

Response from Dr. Frascino

Hello Nick,

Thanks for your kind comments.

Proceeding directly to your specific questions:

1. Even though I have no idea what "possibly lesious" means, I would absolutely agree your HIV risk is negligible to nonexistent.

2. Whether it's "advidable" to take "tablets of stomach bacteria" for "diahrre" is certainly open to question. But I will advise you that you don't have to worry at all about your immune system being down, suppressed or deficient.

3. I absolutely agree the only test you need is one at the three-month mark. Testing prior to that is not considered to be definitive or conclusive. As for treatment of HIV during acute HIV infection ("primary infection"), despite some initial information that looked encouraging, more recent information looks much less promising. Added to this is the increased risk of additional long- and short-term drug toxicity from starting treatment early versus later and the weight of scientific evidence is now swinging toward waiting until the CD4 count falls consistently into the 250-350 range. The treatment pendulum might swing back in the other direction if and when we get less toxic drugs. I'll repost an item from the archives that addresses this topic.

Thanks for your donation, Nick. (www.concertedeffort.org) In return I'll send my very best good-luck/good-health karma that your definitive three-month (or longer) test is negative, as I very strongly believe it will be.

Dr. Bob

Little Benefit Seen for Treatment During Acute Infection Coverage provided by Keith Henry, M.D.

February 9, 2004

Bruce Walker walked across the hall from the immune response session (featuring four Walker-linked studies) to present an update on his highly visible and often-presented small study of patients treated during primary infection who subsequently underwent several sequential treatment interruptions (STIs). The initial results from the study (3/8 maintained <5,000 copies HIV RNA after the first STI and 5/8 maintained <5,000 copies/mL after the second STI) suggested that very early antiretroviral therapy during primary infection, followed by a series of brief treatment interruptions, could lead to improved immune control of HIV off therapy. Those results have stimulated the practice of treating primary infection and spawned enthusiasm that immunologic interventions (such as therapeutic vaccination) could also be utilized in chronic infection. Dr. Walker then presented the longitudinal data for a total of 14 patients (all had acute retroviral syndrome) followed for an average of 5.3 years including for up to 3 years after the last STI. Only 1/14 of the patients has maintained control of viremia (defined as <5,000 copies RNA/mL). The second and third STI failed more quickly, with the fourth STI providing no observable benefit. The rate of CD4 count loss when antiretroviral therapy was stopped was quite high and it was not much different from the CD4 loss observed when stopping antiretroviral therapy in the setting of chronic infection. Dr. Walker then discussed what factors could be identified that could predict the control of viremia. They had looked at HLA type, CCR5 status, GBV-C infection, time of treatment since onset of antiretroviral syndrome (ARS) symptoms, viral load at seroconversion, and anti-HIV immunity from CD4+ or CD8+ T-cells. None of those factors predicted control of viral rebound. Particularly disappointing was the observation that, although anti-HIV immunity appeared to be enhanced with the STIs, this did not translate into observable clinical benefit. These results were interpreted to indicate that durable maintenance of low-level viremia may be difficult to achieve. The CD4 declines were substantial with immune escape at even low viral loads sufficient to be a problem.

In a question to Dr. Walker, Joe Eron made the comment that the window to perhaps protect anti-HIV immunity during primary infection may be vanishingly short. Another questioner pointed out that the definition of failure (confirmed viral load >5,000 copies/mL or one viral load >50,000) made it difficult to perhaps see some attenuation in the true magnitude of viral rebound. Although Dr. Walker stated that randomized clinical trials of early treatment and immune interventions are needed, the enthusiasm about the potential for this to achieve much has waned.

In all, the different presentations on acute infection suggested that we can do much better in finding and preventing recent infections. Although discussed a lot, superinfections still seem to be relatively unusual but are a growing problem. And it's still unclear how helpful treatment during acute infection is. Reference

Abstract: Limited Durability of Immune Control Following Treated Acute HIV Infection (Oral 24) Authored by: D. Kaufmann, M. Lichterfeld, M. Altfeld, T. Allen, M. Johnston, P. Lee, B. Wagner, E. Kalife, D. Strick, E. Rosenberg, B. D. Walker Affiliations: Partners AIDS Res. Ctr., Massachusetts Gen. Hosp., Boston, MA; Howard Hughes Med. Inst.



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