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Frequently Asked Questions (III)

June 1997



On viral load tests, what is considered a high viral load and what is considered a low one? What are these tests used for?

Viral load tests measure how much HIV is in the bloodstream. A result below 5,000-10,000 is generally considered a low result. A result over 5,000-10,000 is generally considered a high result. The primary use of these tests is to help determine if drug treatment needs to be started, or how well a certain antiviral drug is working.

If your viral load is high, your physician may consider starting you on drug therapy, or if you're already on therapy, switching you to another drug treatment. If your viral load is low, this means that no changes in your current treatment may be needed at that time. Viral load tests are best used if trends in results are compared over time. If your viral load increases over time, then the drug treatment may need to be changed. If your viral load goes down over time, antiviral treatment may be working for you.

So rather than just taking one test, a series of viral load tests gives much more useful information. Of course, antiviral therapy must not be determined by this test alone. Other tests (like CD4 cell counts) are also important indicators as to how well antiviral therapy is working. The viral load test is not a substitute for a CD4 cell count. The two tests are best used together. They measure different things: The CD4 test measures how damaged the immune system is from HIV; the viral load test measures how much of the virus is in the bloodstream. In other words, the viral load test measures the cause of immunosupression (HIV), and the CD4 test measures the effect (how badly the immune system is damaged). The lower the viral load, the better the outcome -- the better a person is expected to do.

The viral load test should not be used for routine HIV testing in adults (that is what HIV antibody tests are for). Also, these tests cannot be used to determine if a person is "cured" of the infection. A viral load test that is "below detectable levels" does not mean that you don't have HIV. If your viral load is very low, the test may not be able to detect it. Also, HIV can live in tissues of the body (like the lymph glands). The viral load test only measures the amount of virus in the blood, not the entire body. So a viral load test that doesn't pick up HIV does not mean that you're not infected, or that you are cured. It does, however, mean that there is very little virus in your blood, which, clinically, is good news.

Viral load and CD4 testing should be done soon after the diagnosis of HIV is made. After a person is initially diagnosed with HIV, the doctor may wish to do these tests twice, several weeks apart. It is then recommended to get these tests every three to six months. Testing may be needed more often if more information is needed by the physician, or if the patient's clinical status worsens. When a person begins a new therapy, the physician will usually do a viral load test after about a month, to see if the new therapy is working.

The following is a general summary of the Updated Recommendations of the International AIDS Society, USA Panel (Journal of the American Medical Association. 1997;277:1962-1969). These recommendations may not apply to everyone, but it's always important to talk to your doctor first as to when to start or change treatments.

  • When to begin therapy:

    1. Viral load greater than 5,000-10,000 regardless of clinical status = Consider beginning treatment. Retest every three to six months. (For more on this, look at The Body's section When to Begin Treatment.
    2. Symptomatic disease, or a CD4 cell count less than 500µ or especially if the CD4 cell count is less than 350µ = Consider beginning treatment.

  • Goal of therapy:

    Viral load reduced to undetectable levels, or less than 50-500, depending on what test was used.

  • When to change therapy (always discuss with your physician about changing your treatment, or adding to your present treatment):

    When viral loads increase, other causes should be ruled out first, before changing therapies. These include not taking medications correctly, recent vaccinations and other illnesses occurring at the same time. Remember that when you change or begin therapies, decreases in viral loads often will occur in the first two to four weeks. However, it may take 12-24 weeks for a new therapy to have its maximum effect.

    1. If your viral load was below detectable levels, and has risen to 2,000-5,000 = consider changing therapies.

    2. If your viral load never went below detectable levels, and has risen greater than 5,000-10,000 copies = consider changing therapies.

    3. If your viral load increases to where it was before treatment, or remains unchanged = consider changing therapies.

    4. If there is a decline in CD4 counts or there is a progression of the disease = consider changing therapies.

    5. Severe (toxic) side effects = Do not reduce the dosages of any of your drugs, unless you have been specifically told to do so by your physician. This is especially true with the protease inhibitors. Reducing the dosages can lead to drug resistance.

    For more on changing treatment, see Changing/Stopping Treatment.


How often should I do viral load testing?

  1. When being tested for the first time, establish a baseline by being tested twice, two to four weeks apart.
  2. Then get tested every three to four months or get a viral load at the same time you're getting a CD4 cell count.
  3. Sometimes testing may be needed more often if more information is needed by your physician, or if your clinical status worsens.
  4. When starting on antiviral therapy or changing medications, have a viral load test done three to four weeks later. Also do a CD4 cell count as well. This is to see how well you are responding to the medications.

For more on viral load testing, see The Body's Ask the Expert forum or see The Body's section on viral load.


I can't cope with my fear of AIDS. What should I do?

There are many people who have a hard time accepting the fact that they are HIV negative, even though they have tested negative six months or more after a possible exposure to the virus. There are also many people at low risk (or no risk) for HIV infection, yet they have a hard time accepting that fact. In both of these cases, most of the time, the true issue is not HIV/AIDS. Often the true issues are those of guilt, shame for something they may have done, an irrational fear of AIDS or other psychological problems. Often, counseling is the best solution for people in these circumstances.

If someone continually thinks that he or she is one of those rare individuals who will take longer than six months to show up as HIV positive, or if they think that they'll be that first person to get HIV by kissing, then that person could needlessly stress themselves to the point that their lives can become destroyed by their fear of HIV/AIDS. Counseling is often the best solution to dealing with these types of problems. To determine if counseling may be an option for you, ask yourself these questions:

  1. Are you still scared of getting HIV/AIDS, even when you've been told you're at low risk (or no risk) of getting the infection? Are you having a difficult time accepting the fact that you are at low/no risk?
  2. Are you still scared of having HIV, even though you have tested negative six months or more after a possible exposure to the virus? Are you having a difficult time accepting the fact that you are HIV negative?
  3. Are you having a difficult time waiting six months before getting tested? Are you having a difficult time coping with this six month waiting period?
  4. Are your fears interfering with your day-to-day life, especially on an ongoing basis?

If you have answered yes to any of these questions, then please consider getting counseling. In situations such as these, counseling is often a better solution than getting tested over and over and over (beyond six months after a possible exposure). It is also a better option than taking specialized tests such as PCR tests, antigen tests, viral cultures, viral loads, CD4 cell counts, etc. In these situations, getting all these tests, or getting tested over and over, does not solve the source of the problem. Counseling is often the best solution for people who cannot accept the fact that they are HIV negative, or that they were at low risk (or no risk) of infection.

In addition, counseling is often the best option for people who "just can't wait six months to get tested." Counseling helps people to learn to cope with the six-month period of time before getting tested. Counseling can be a much better alternative than taking PCR tests, or any other specialized tests.


What is viral hepatitis, and how is it transmitted?

The word hepatitis means inflammation of the liver. Not everybody who has viral hepatitis (type A, B, C, D, E or G) will get symptoms. In those who do, the symptoms can be either mild or severe. People with acute hepatitis can have flu-like symptoms (muscle aches, body aches, mild fever, malaise), lack of appetite, nausea, vomiting and fatigue, as well. They may also have abdominal pain and tenderness. In very severe cases, a person can turn yellow. This is called jaundice. There are also non-viral causes of hepatitis, which can cause very similar symptoms. It's important to remember that most of these symptoms resemble those of many other illnesses. To determine the cause of their symptoms, it's best to see a physician and get tested. Having these symptoms can be due to numerous causes other than hepatitis. This is why laboratory testing is so important to diagnose these symptoms. And again, many people with hepatitis have no symptoms at all.

Some forms of hepatitis (especially hepatitis B or C) can lead to cirrhosis of the liver and liver cancer, usually years after infection. Some people who have hepatitis (especially hepatitis B or C) can die of the infection.

Hepatitis A is transmitted through the oral-fecal route. It is usually transmitted via contaminated food. Sexually, however, it could be transmitted by giving oral-anal sex (rimming) to an infected person. It is not transmitted by intercourse. In terms of when a person starts showing symptoms of hepatitis A after they're infected, the incubation period is 15-50 days, with an average of 28-30 days. Someone would start showing positive on a hepatitis A antibody test during the acute illness, and for about four to six months afterwards. There is now a very effective vaccine against hepatitis A.

Hepatitis B is transmitted the same way as HIV, however hepatitis B is up to 100 times more infectious than HIV. If a person engages in unprotected sex or shares needles, infection with hepatitis B would be a possibility, even more so than HIV (assuming the partner is infected with either virus). The incubation period (when a person starts showing symptoms) for hepatitis B is usually 45-180 days with an average of 60-90 days. There is now a very effective vaccine against hepatitis B.

Hepatitis C can occasionally be transmitted sexually as well, although it's most often transmitted through direct blood-to-blood contact. The incubation period for hepatitis C is two weeks to six months, but most commonly six to nine weeks. There are tests for hepatitis C, but they often can't distinguish between recent and previous infection. Improvements to hepatitis C testing are currently underway. Vaccines that have been developed against hepatitis A and B will not protect you against hepatitis C or other forms of hepatitis.

Hepatitis D (also known as delta hepatitis) is transmitted the same way as hepatitis B. If a person has hepatitis D by itself, it is harmless. But if a person has hepatitis B and hepatitis D, this can cause serious illness.

Hepatitis E is most often found in developing countries. It is transmitted the same way as hepatitis A.

The recently discovered hepatitis G virus is transmitted through blood-to-blood contact, and there is some suggestion that it may be sexually transmitted as well. Mother-to-child transmission has also been reported. This virus has been linked to both acute and chronic hepatitis. The symptoms it causes tend to be mild, and jaundice may not be seen. Because hepatitis G has been so recently discovered, there are still a lot of things we don't know about it.


Where can I get more information about HIV/AIDS and other sexually transmitted diseases (STDs)?

If you have additional questions, first look on this website for information on topics that you are interested it. There are already a wide variety of questions and answers about AIDS and STDs on this website. If you have additional questions that you cannot find, you can do one of the following:

  1. Send us a public question on this website. Your e-mail address and name will NOT be revealed to anyone. Please make sure that your question does not already appear on the website. Similar or idential questions will be posted only once. This is to keep the website as readable as possible, and to make the website easier to read. To leave a question here, click on ask a question on this web page. The answer to your question will be posted as soon as possible.
  2. Call the U.S. Centers for Disease Control and Prevention 24 hours a day, seven days a week, at 1-800-342-AIDS (2437). (If you're calling from outside the United States call 1-301-217-0023.)
  3. Click here to find a local AIDS hotline, Canadian hotline, or international resource.



Do you want more information on AIDS, STDs or safer sex? Contact the U.S. Centers for Disease Control AIDS hotline, open 24 hours a day, seven days a week, at 1-800-CDC-INFO. Calling from outside the United States? Call 1-301-217-0023. Or visit The Body's Safe Sex and Prevention Forum.

Until next time . . . Work hard, play hard, play safe, stay sober!




  
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This article was provided by Rick Sowadsky, M.S.P.H..
 

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