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question about hidden HIV follow up
May 18, 2006

Hi Doc,

So then in the case of people that has undetectable Viral Load without any kind of medication, what test will tell them if the are finally virus free? (besides VL test)

May 3, 2006

Dear Dr. Daar,

I wonder if you can clarify this for me.

Where exactly does the HIV hide? if I can bring my VL to undetectable, then if they draw some blood to do a Western Blot it will still be Positive? Do the cells infected with HIV become anaerobic? have u heard anything about Protocel that supposedly eliminates infected (or anaerobic) cells?

If one can make this hidden HIV come out while taking Meds, there is a change to get rid of it?


Response from Dr. Daar

Let me clarify a few things and then try to directly answer your question. First of all, when we say someone is HIV-positive we are generally referring to the fact that their standard test for HIV, the ELISA and Western blot is positive. These tests tell us that the person's body has been exposed to the virus and has developed antibodies to it. This is true with most infections and in general the antibodies persist in the body for many years if not life. What makes HIV different than the majority of viruses is that having antibodies means that not only was the person exposed but that they are also persistently infected. Therefore, the Western blot remaining positive is not what defines that the virus is hiding in the body.

What I mean by persistently infected, and I suspect you mean by the virus hiding in the body is that everybody who has been exposed, and therefore has antibodies actually has virus present. This we can proven by the ability to dectect HIV with viral load tests which actually tell us how much virus is circulating in the blood. When effective therapy is used to suppress viral load to below the limits of detection by the available assays we know that cure has not been achieved because in virtually all cases when therapy is stopped the virus promptly rebounds to detectable levels. Therefore, despite viral load being undetectable on therapy it is presumed to be "hiding" somewhere in the body.

There are several places the virus may hide in those on potent antiretroviral therapy. This includes being in cells circulating in the blood, so called "resting memory CD4 cells." While they are referred to as resting or not activated, the word "anaerobic" would not be the right term to describe their condition. It is certainly possible that the virus hides elsewhere as well, such as in the brain. Regardless, it is felt that the persistence of virus in resting memory cells is at least one of the reasons why we are unable to cure people of HIV with available therapy.

So, what to do? There are many groups testing strategies to activate these resting cells with the hope that they will then be eliminated from the system and allow for the possibility of viral eradication. Although there is a long way to go before "cure" is possible, if it ever will be, that doesn't mean that we should give up the fight for this ultimate goal. In the interim, the next best thing to a cure is long-term control of infection and prevention of disease progression. In this arena there has been tremendous progress!!

Best, Eric

Response from Dr. Daar

I am assuming that the hypothetical person you refer to is HIV antibody positive by the ELISA and Western blot. If so, it is generally assumed that they are HIV-infected. There are some people who are infected who do maintain viral loads below the limits of detection even without antiviral medications. Occasionally this is because the assay is just not able to detect their specific type of virus, but often it is because they truly have outstanding control of the virus. There is no reliable test one can use in clinical practice to detect virus in these people, although there are some commercial laboratories that will test for HIV DNA in blood cells. Unfortunately, even a negative HIV DNA test would not necessarily prove the absence of infection. There are other research methods that have been used that support the fact that most of the people that you describe, if not all are indeed infected.

I hope that helps further clarify things. Best, Eric

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