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Confusing test results, viral load undetectable but positive on all results
Mar 28, 2011

Dear Dr.Bob,

First of all, many thanks for everything - last 2 months have been the scariest of my life and I do not know what I would have done (something self destructive for sure) if it hadnt been for your website and another caring HIV specialist I personally know. Although there are still many tough battles to be faught on family, social and other fronts as I am from a very conservative sociaty in a developing world, thanks to info available on your site, I have chosen to live and make the most of whatever is available of this opportunity called life.

One aspect of my question is somewhat similar to the one posted on Jan 27, 2011 (recently diagnosed with hiv but no viral load) but for my sake, please do respond - it will help someone who is in a lot of distress.

I am a 28 yr old male from a developing country. I had an exposure on 25th Dec 2010 and got tested by ELISA on 9th Jan 2011 and tested positive. Thereafter, I retested by ELISA on 14th Jan 2011 and by HIV DNA PCR on 17th Jan 2011, all of which came positive/ detected (reason I did a DNA PCR was as I had previous history of Hepatitis B 2.5 years ago but I had cleared the virus within 4 months then and later repeatedly tested negative on HBV ELISA; my HIV specialist thought I may have some cross reacting antibodies). Thereafter, I got my first RNA PCR test done on 25.2.2011 and the results were: VL <48 copies, CD4 621 (23%), CD4:CD8 = .5. We were surprised by the results and as recommended, I got a confirmatory western blot test which also came positive for almost all bands. To discuss treatment options and to rule out any lab error, we got a second RNA PCR test on 10.3.2011 at a different diagnostic and the results were almost exactly the same: VL <48 copies, CD4 621 (23%), CD4:CD8 = .5. To rule out HIV - 2 which cannot be read with RNA PCR, I had a tridot test which indicated that I was infected with HIV 1 (as also indicated by the western blot where antibodies for HIV-2 were negative).

Now I have read your response to the question earlier on Jan 27, 2011 (recently diagnosed with hiv but no viral load) and read your opinion on the probability of us being 'elite controllers' but I wanted to request your expert comments/opinion on the following:

1.Isnt it highly unusual to have undetectable viral load exactly within 8 weeks of seroconversion? And thereafter to again have undetectable viral load within 10 weeks of seroconversion? Even if someone is a slow progressor, they should atleast have a detectable viral load in the initial phase where VL of 1,00,000 - 1 Mn is considered 'expected and normal'. Atleast if VL would have been detectable initially and then become undetectable, it would have been more on lines of 'slow progressor'. Irony being that I have always been a 'sick' child or someone who fell sick more than others due to slightly lower immunity.

2. Since the VL has never been detected, can it happen that the ELISA, Western Blot and DNA PCR test results show false positive? Do I need to repeat DNA PCR and would I be HIV free if this test comes undetectable? (I know from this site that ELISA + Western Blot is gold standard and accurate and adding a DNA PCR which came detected is even more accurate but still ask this question as I had a previous history of Hepatitis B).

3. Assuming that the RNA PCR test results are accurate, I have postponed the decision for starting medications yet. I intend to get my numbers every 4 months, is that ok? Currently, apart from depression, all my other tests including liver tests are normal. But another question, with the recent research recommending treatment even with lower viral loads (due to unchecked damage it does to immune system even at these lower levels and as VL tests only measure the virus circulating in the blood), should someone who naturally has an undetectable viral load opt for first line ARV regimens while he is undetectable or wait till the Vl increases or CD4 declines?

4. I am a married man and somewhere in early June we plan to conceive (my spouse is negative, thankfully) by IUI Intra Uterine Insemination method combined with a procedure to pick the most active sperms (centrifugal spinning at high speed to separate other semenal fluid and less healthy sperms). I know this may or may not be exactly what we call 'sperm fishing' as this procedure may not be available in our country. But my question is, assuming this procedure separates most of the semenal fuild from the active sperms which is then actually inseminated artificially and assuming that I continue to naturally have an undetectable viral load till june, how safe would this procedure be to preserve my spouse's HIV negative status? Would we be eliminating risk completely to 0.00001% considering also that exposures would be limited to 1 attempt per cycle comparing to 6-7 attempts using the hocus pocus unsafe sex timing method?(I ask this for 2 reasons - sperm fishing in our country is not being called or done exactly as I understand from the web and since I would theoretically be 'undetectable' in June at the time of procedure not due to being on ARVs for 6 months continuously as recommended but for some other strange reason such as being a slow progressor).

5. Can Slow progressors or Elite controllers be expected to live normal life spans like a HIV negative person or does the viral load find a way to increase after a period of time even in these individuals. If so, what is the expected duration of remaining

Your frank and detailed responses as usual would be like a life saver for me and help me greatly by way of empathy and support. Please do respond. God Bless.

Response from Dr. Frascino

Hi,

1. Elite controllers in and of themselves are "highly unusual." Consequently, that you had an undetectable HIV RNA PCR viral load eight weeks after seroconversion is only unusual because you appear to be one of a very small group of HIVers who can control HIV viral replication. Please note, an "elite controller" is different from a "slow progressor."

2. No. You are convulsively HIV infected. Multiple positive tests involving ELISA, WB and qualitative HIV PCR DNA are definitive.

3. There is no consensus here. The verdict on whether or not elite controllers should be encouraged to begin antiretrovirals is still out. Some immunologists favor starting to prevent damaging immune activation. Some HIV experts prefer to wait and monitor lab results every three to four months.

4. Unfortunately I cannot give you an exact answer, as your situation is indeed "highly unusual." Certainly an undetectable HIV plasma viral load decreases the risk of HIV transmission (but doesn't completely eliminate it). I'm not an obstetrician and can't really comment on the "sperm fishing" technique you describe. "Sperm washing" does decrease HIV-transmission risk. You can read more about this in the archives. You should discuss your options with an HIV-knowledgable obstetrician. Possibly a course of PrEP (pre-exposure prophylaxis) for your wife could be considered.

5. No one knows. There are a number of elite controllers being followed closely in clinical studies. However, since HIV wasn't recognized until the 1980s and we didn't have good monitoring tests until a number of years after that, we can't really determine what the long-term morbidity and mortality will ultimately turn out to be. It is worth noting that not all elite controllers remain elite controllers. Sometimes the virus defeats the host's immune control and begins to replicate. That's why monitoring is so important.

Good luck.

Dr. Bob



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