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Follow-up question regarding labs/diagnosis
Mar 30, 2008

Hello, Dr. Bob.

I wanted to follow-up with you regarding my apparent HIV infection. Below is the text of my questions to you (and your responses) from July and August of 2007.

Due to lack of insurance as well as the input of my current doctor, I have not (yet) done the proviral HIV DNA test you recommended. I also have not (yet) repeated the Western Blot test that was "indeterminate" per Red Cross (but "positive" per CDC criteria) back in July of 2007 (both Elisas were positive at that time). However, since I last wrote to you, I have had my T-Cells and VL tested a few times. The results are: 07/07: Tcells: 795 (44%), VL: <50; 09/07: Tcells: 629 (43%), VL: 895; 12/07: Tcells: 854 (45%), VL: <50; 03/08: Tcells: 880 (45%), VL: 151.

So, my doctor thinks there is no question that I am HIV-positive due to the two detectable VL measures. I mostly agree with him, but still question why my viral load is so low since I tested HIV+ in 06/2007 after testing HIV- repeatedly (for years) and my last negative test result was one year earlier. Isn't my VL very low for somebody who theoretically (based upon dates of last negative test and first positve test)was infected around 01/2007? (Also, that VL of 895 came about 2 weeks after I had measles-mumps-rubella booster shot (necessary for graduate school, which I have since dropped out of).) It's been suggested to me by a knowledgable lay person that I might be an "elite controller".

Anyway, if you have any comments or insight that you'd be kind enough to share with me, I'd truly appreciate. Thanks again for your thoughtful response to my earlier questions and for all the good work that you do.

Namaste.

------------------- Your suggestion of a HIV DNA test?

Thank you again for answering my question from last month. I saw my doctor last week and showed him a printout of my question to you and your answer. He was not clear on what sort of "HIV DNA" test you were suggesting and asked that I contact you for clarification. Is it the "qualitative assay for proviral HIV-1 DNA" that you are recommending? Thank you again for your time and willingness to help. My earlier question and your response: Please help me understand Western blot results Jul 11, 2007 I get tested for HIV about once a year at a local anonymous testing site. I tested HIV-negative in the summer of 2006, but a couple of weeks ago, I had a rapid fingerprick test come back "faintly" positive (i.e. a barely perceptible pink line at the "T" mark). The counsellor first told me I was HIV-negative and then looked again at the dipstick and wasn't sure. I requested another rapid fingerstick test and it was also faintly positive. I left without providing a blood sample for additional testing. The next day, I went to another testing site and the oral swab test had such a light pink line at the "T" mark that the counsellor wasn't sure what it meant. We did another finger-prick test and that was negative (no line). I went to my doctor two days later and submitted a blood sample for Elisa and Western Blot tests as well as another sample for HIV RNA viral load. The Elisas came back as positive as did the Western blot, but the HIV viral load came back as undetectable. The Western Blot band results are the following: P18 Reactive P24 Reactive P31 Indeterminate P40 Reactive GP41 Indeterminate P55 Reactive P65 Indeterminate GP120 Indeterminate GP160 Reactive My questions are the following: What is the difference between "Indeterminate" and "Negative" results for the WB bands? (I had no "Negative" results, but I assume they exist.) According to some reading I've done online since getting these results, it seems that prior to 1993, my WB would have been considered "Indeterminate" due to the non-reactive P31 band. So, is there any hope -- especially since my viral load is undetectable and the longest I could have been infected is a year and I've obviously had no treatment -- that I might have some false positive results here?

Response from Dr. Frascino Hello, Your ELISA is reactive (positive); your Western Blot (WB) is indeterminate. Indeterminate means the presence of any band pattern that does not meet the criteria for a positive test result. Negative means no bands. A positive WB is defined as reactivity to gp120/160 plus either gp41 or p24. You have reactivity to gp160 and p24; consequently, the odds are very strong that you are indeed HIV positive, despite the indeterminate results for gp120 and gp41. The causes of indeterminate Western Blot tests include serologic tests done during the process of seroconversion, late-stage HIV infection, cross-reacting nonspecific antibodies, infection with O strain or HIV-2, HIV vaccine recipients and technical or clerical errors. The most important factor in evaluating indeterminate results is risk assessment. Folks in low-risk categories with indeterminate tests are almost never infected with either HIV-1 or HIV-2. I don't know what your risk profile is. I would suggest you contact an HIV specialist in your area for additional follow-up. A repeat of your serological tests, plus a DNA PCR and evaluation of potential causes for indeterminate or false-positive results by the HIV specialist should firmly and definitively establish your HIV status one way or the other. From the information you presented, close follow-up for presumed primary HIV infection is certainly warranted. Good luck. I'm here if you need me. Dr. Bob

Hello, Yes, the "qualitative DNA PCR" is used to detect cell-associated Proviral DNA, including HIV reservoirs in peripheral CD4 cells and has a sensitivity down to approximately 5 copies/106 cells. However, this test is not considered sufficiently accurate for diagnosis without confirmation. Consequently, repeating your serology would also be warranted to firmly establish your status one way or the other. Good luck. I'm here if you need me. Dr. Bob

Response from Dr. Frascino

Hello,

Both you and your doctor are not certain if you are HIV positive or not and yet you've run three sets of T-cell subsets and HIV PCR RNA viral load tests? This makes absolutely no sense whatsoever. You have not repeated your indeterminate Western Blot because of "insurance as well as input from (your) current doctor"??? What??? Your insurance has no problem covering extremely expensive T-cell subset analyses and viral load tests but won't cover a very inexpensive repeat ELISA and Western Blot (if the ELISA is positive)??? That's absurd. And frankly I don't believe it. Second, this "input" from your current doctor also sounds somewhat suspect. I would strongly urge you to get a second opinion from a certified HIV specialist (as I previously suggested) to sort out your status once and for all. Relying on "knowledgeable lay persons" and the Internet to resolve this issue is unwise. If you need help locating a certified HIV specialist, check the American Academy of HIV Medicine's Web site at www.aahivml.org. There you will find a roster of HIV specialists listed by locale. There is no need for persistent uncertainty regarding your HIV status.

Dr. Bob



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