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Complicated Case Returns
Oct 9, 2006

Hello Dr. Bob

I am afraid this will sound clichéd, but Dr. Bob I have visited your site often and I have to tell you in you I have witnessed the best of humanity, the absolute pinnacle you have opened my eyes to a lot of things and rid me of all my prejudices. Unfortunately, there have been timely reminders of the worst in humanity, in some of the hates mails you get. I am sure you dont worry about these assholes.

Well, its the return of Mr. Complicated. I certainly hope you remember me. A positive viral load test, which I think was a false positive (the lab and my Drs believe this), 6 weeks of PEP/ARV because of this result. I am sure you have the details in your record.

As you recall my 2 exposures of concern were medium risk, unprotected sex with women 3 months ago and the last at 11 weeks ago. You have rightly stated that all the viral load tests I had was invalid as I was on PEP. However, I think that Qualitative DNA Proviral test would still be valid, as these could detect even dormant viruses in the blood that are not replicating. I had two of this done, at 4 week and 6 week mark. I also had WB and ELISA (with P24) done at 6 week and 8 week mark.

My concerns are as follows is it likely that my first test of VL of 25,000 copies was a true positive. I have read that false positives usually have a low viral count, i.e.< 2,000. And the subsequent test were made undetectable due to PEP, (I had been on two weeks of PEP). But this would be illogical since the second test sample was taken just 3-4 days apart, and it came undetectable. Can the PEP or ARV be that effective? After receiving the positive result, I had it verified with a VL test at the second lab about 6 days after the first sample and that was also undetectable.

The Dr (who I now think was a quack), I was seeing at that time believed that this result of 25,000 copies was true (until proven false). And since VL was at a high setpoint, he thought I had virus for a long time. (This made me concern about all the encounters I had in the past, which were a few (one) I did not believe were risky at that time.) He could not offer a logical explanation as to why my baseline ELISA was negative. He later also changed his opinion about the initial test after subsequent tests were negative/ undetectable/ nonreactive.

What do you think could be possible explanations for a false positive result. I had a hepatitis shot at that time, also had genital herpes outbreak a few days after. The lab also thinks the samples could mixed up (as it receives 1,000s of sample from all over the country) and since it is in a different city to mine, my sample had to be flown to this lab thus more room for error. However, the pathologist thinks that mistake could have occurred in the handling. I think the third explanation biological disposition. But I would sincerely appreciate your opinion Dr. Bob.

Now for some good news I visited Singapore and got tested by Abbot rapid blood test (conducted by the great guys at AFA) and Oraquick oral test at a private clinic, both negative at the 10 and 11 week mark. I know this is not 3 months mark, but is this indicative of good news?

Do you still think that 3 months (12/13 week) test would be definitive for me, considering my 6 weeks of PEP and a (false) positive VL test. When do you think I can woo hoo and get on with my life, forgive myself for cheating on my wife.

Oh, yes I promise to donate, hope this will be in person, what a photo op that will be for me. But seriously, I think I would be in financial trouble if I am infected because I originally come from an underdeveloped country which does not have any national health schemes, they dont even have ARVs.

Love U Dr. Bob Mr. Complicated

Response from Dr. Frascino

Hello Mr. Complicated,

Welcome back to the forum. Once again I strongly disagree that your situation is at all complicated. Rather, your experience is simply the result of multiple errors in judgment. My assessment of your situation and advice remain unchanged from your original post (reprinted below). I see no real value in trying to identify or explain why a test that never should have been ordered produced a result you didn't expect. Viral load testing is not indicated for routine HIV screening. Period. Therefore interpretation of these test results becomes a moot point. What we can determine with great certainty is that your 25,000 copies VL test was a "false-positive".

Next, qualitative proviral DNA tests can be helpful in selected cases for identifying primary HIV infection prior to the development of detectable anti-HIV antibodies. However, once again, it is not recommended or FDA approved for routine HIV screening. That you've had two of these plus two additional ELISAs, p24s and WBs, all during the first eight weeks, is yet another error in judgment. To this you've now added rapid tests at the 10- and 11-week mark.

Clearly you did not heed the advice I gave in my initial response. As mentioned above, my assessment and my advice remain exactly the same:

1. A single HIV-antibody test at the three-month mark is all that you ever needed to confirm your HIV-negative status. (Tests taken prior to three months are not considered definitive. PCR tests are not recommended for routine screening.)

2. You need treatment for your anxiety, guilt and irrational fears of being HIV positive. To this I would add you should level with your wife. It's not only the best way to confront your guilt, but it's also the right thing to do.

3. Never vote Republican.

Thanks for your willingness to make a tax-deductible donation to The Robert James Frascino AIDS Foundation (www.concertedeffort.org). I am more convinced than ever that your "un"-complicated case will have a very happy and healthy ending. I look forward to your uncomplicated WOO-HOO!

Dr. Bob

Complicated case (amended)

Sep 8, 2006

Dear Dr. Bob

I am a hetero sexual male 33. I am also married but strayed a couple of times in the last 3 months. My last exposure was 7 weeks ago, me giving anal sex to a girl without protection, who said she had been tested and was negative, I am still in touch with her. I was inside her for about 5 mins or more before coming to my senses, withdrawing and washing. She also had her period during that time. I dont know whether any blood had got onto my penis from our encounter. Before this I had sex with a girl (student) when the condom broke, but I carried on unaware. This girl had also tested and was negative on ELISA/qualitative PCR after 12 weeks after our exposure. Anyway the GP I saw straight after my last exposure (48hrs) possibly misinterpreted my exposure risk and offered a basic PEP regime (duovir) and I went on it just to be on the safe side. My baseline ELISA was negative.

Another Dr. (a dermatologist) recommended a PCR RT Quantitative test, 2 weeks after which surprisingly came as positive with 25,000 copies. This is where my nightmare started. I had also given a second sample of blood (4 days after) to the same lab. After receiving the result still in a state of shock, I went to a different lab to have the same test done about 6 days after the first sample was given. Based on the first unconfirmed result, having a high viral count I was also put on ARVs by the same Dr. The lab that did the initial PCR, (I deduced later) found that the results of the first blood sample and the second sample were not matching and requested me to give a third sample 7 days after the first sample was given. Both of the two subsequent tests were not detectable i.e. negative. The lab, to make sure, also did a rapid immunocomb test and western blot test. It then said the first test was false, and admitted to their mistake but couldn't explain adequately where the mistake had occurred, most likely in the handling of the sample or interpretation. The PCR RT test at the second lab was also negative.

I was pretty distraught and saw an expert in the field of HIV. He recommended a DNA Proviral Qualitative test. I also got this done (3 weeks after the exposure) at the lab that had made the original mistake, this was also negative. I confirmed this with the pathologist there who had taken a personal interest in my case. This Dr was very encouraged but said that I should continue with the ARVs until 6 weeks post exposure, and stop after ELISA test is negative. This was because he did not want to lose the efficacy of the ARVs just in case I had the virus.

6 weeks after my exposure, my HIV 1,2 p24 test came negative. I also sent a sample for another PCR DNA qualitative test which also was negative, the lab again had run PCR RT, Immucomb rapid and western blot test as backups, as a favour to me, all negative.

I now have stopped ARVs, I still suffer from anxiety, also fear that with no ARVs or PEP, I am now seroconverting, suffering from mouth ulcers and sore throat. I don't have fever or rashes, but do get stiff neck and upper body muscle pains, I have these symptoms for 5 days.

My question is there a chance that I am now seroconverting because I am no longer on PEP or ARVs. Could they have interfered with my 6 weeks extensive test results and other negative tests after the first false positive. Did the lab really make a mistake, or were they right the first time. Logic dictates that they did make a mistake and they admitted it, because how can results be so different just within 4 days. I had been on 2 weeks of PEP at that time, maybe that interfered with the results of the second, third, 4th, 5th 6th PCRs both qualitative and quantitative. Also the Western blot, ELISA and Rapid Immunocomb. Sorry if I sound like the most tested person on the face of this earth.

My GP and the Pathologist, who is quite renowned in her field says I have nothing to worry about. Do you agree.

Your response will be greatly appreciated and thank you for all your good work.

Response from Dr. Frascino

Hello,

There were several errors in judgment in this "complicated case" (which really shouldn't have been complicated at all!).

These errors in judgment include:

1. Your having unprotected sex.

2. The dermatologist recommending a PCR. First off, PCRs aren't recommended for routine screening, due to the possibility of false-positive tests. (I guess you learned this fact firsthand from your experience!) Second, ordering a viral load test while you were on antiretrovirals (PEP) to diagnose a potential HIV infection makes no sense whatsoever. (The antivirals could suppress HIV replication to undetectable levels, thereby giving a "false negative.")

3. Being placed on ARVs because of a spurious test result.

4. Continuing ARVs for six weeks when there was really no reason to do so.

My assessment of your situation is simple:

1. You had an HIV risk, unprotected sex, for which you should have gotten a single HIV-antibody test at the three-month mark to ascertain if you had contracted the virus.

2. Your initial PCR was a false-positive, once again demonstrating why I don't recommend them for routine screening.

3. I do not believe you are seroconverting, but I do believe you are suffering from anxiety, a condition for which I suggest you seek treatment. Because you remain so worried, I would suggest you get a single HIV-antibody test at the three-month mark. The odds remain astronomically in your favor that you did not contract HIV.

Your nightmare has several take-home lessons:

1. Unprotected sex isn't worth the risk.

2. HIV specialists should be consulted, if PEP is started, to assess the risk, optimize the therapy, manage complications and interpret follow-up tests.

3. PCR testing is not recommended for routine HIV screening.

4. Never vote Republican. (OK, I just threw that one in for good measure.)

Good luck. Fortunately for you, your complicated case will have a happy ending when all is said and done.

Dr. Bob



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