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Managing Side Effects of HIV TreatmentManaging Side Effects of HIV Treatment
           
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I really respect your courage in stating the truth
Jul 20, 2004

I must salute your courage and knowledge in stating a fact - that there are rare cases where people infected with HIV do not develop antibodies, even if not agammaglobulinemic. This does reinforce how crucial prevention is.

But, I am curious - is there any information out there as to why these atypical cases occur? Can nutritional deficiency/low IgM and IgG serum and/or low B cells be the reason antibodies do not develop...maybe low alakaline phosphotase, which seems important in making many ELISA's work properly?

Has science/medicine attempted to understand these rare cases and would a negative DNA PCR or RNA PCR definitively rule out a case where there is an atypical host response (no antibody development)?...or can there just be some rare strains of HIV that are simply undiagnosbale in unusual cases?

Many thanks - and especially for being so much better informed and willing to state an axiom that some clinicians do not know about or refuse to acknowledge.

Regards.

Response from Dr. Conway

Thank you so much for your kind comments.

If an antibody response does not develop in the setting of proven HIV infectiion (an EXTREMELY, EXTREMELY RARE OCCURENCE), the issue is likely with the immune system. It is either unable to produce antibodies because of some deficiency OR (and this may be the most interesting part) it may be that the initial viral insult was so well controlled by the host's cellular immune response that there is not enough antigenic stimulus to provoke the synthesis of antibodies. These latter rare cases may give us some insight as to how the body may sometimes control HIV on its own (this would be the extreme of the long-term non-progressor). Did I say this was EXTREMELY RARE?

On another note, a negative HIV DNA test performed on the right cells effectively rules out HIV infection. I will remind us that HIV RNA is not diagnostic test and should not be used to rule out the presence of HIV infection in these touchy, difficult cases. It is quite useful to diagnose acute HIV infection, though, with a negative antibody test result and a documented recent exposure.

In theory, there is a research-based test to detect reverse transcriptase in the blood (as a surrogate marker for the presence of a retrovirus infection when all other tests are negative), but this is as much a theoretical concept as anything else. You will find it mentioned in the medical literature, however.



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