Just tested HIV positive and scared

Question

First of all I would like to thank you for the great job you are doing through this site. Thank God I found you!

My boyfriend was tested negative about 4 months ago. Unfortunately, at the beginning of May he had to to be hospitalised due to high and constant fever, swollen lymph nodes, Candidiasis, extreme fatigue and most of the symptoms expected during primary HIV infection.

Unfortunately, the HIV test gave positive last week, with CD4 count 140, and VL 140,000.

His doctor has informed us that he won't start my boyfriend on any medication until genotyping tests for HIV resistance are performed. This worries me as the genotyping tests may take quite long, during which my boyfriend will continue to have such low levels of CD4 and high viral loads. He will, however, start taking Cotrim as his doctor is worried he may have a lung infection.

Do you think it is reasonable to wait for the resistance results, or should he start straight away with medication and modify it at a latter stage depending on the resistance tests?

His doctor has also informed him that with his CD4 counts and VL, he will probably have to be always on medication. Is this correct? I thought that if during medication his CD4 cells go up to reasonable numbers, and his VL goes down to low or undetected levels, he would be able to take a break on medication.

Thanks again for the help you are all giving us.

Answer

This is a difficult situation for both of you.

If your boyfriend was truly negative 4 months earlier, he is most certainly going through acute HIV infection. During this phase, the CD4 cells can drop dramatically as the viral load peaks. But, in most cases, the viral load will come down to some level and stay there. The CD4 cell count will then rise again, even to normal levels. This is all without the use of HIV medications. Certainly, in some cases, the viral load can stay high and thus the CD4 cell count low, but this is rare.

Whether to treat people with acute HIV infection is still not firmly established. In locales where there are knowledgeable clinicians and access to medications and laboratory testing, many clinicians are prescribing antiretroviral therapy during acute infection to try and preserve the parts of the immune system that are dedicated to fighting HIV. These parts are often destroyed by the virus early in infection. There are still many questions like which are the best drugs to use and for how long. Still, in my clinic, I start people with acute HIV infection on medications (e.g. Truvada and efavirenz).

I would not wait for a genotype to start therapy. If the test comes back a week or so into therapy and indicates resistance, the regimen can be altered with minimal risk of resistance developing in the interim.

If therapy is started it is not clear that it need be life long. Some experts advocate stopping therapy after 6 or 12 months following acute infection - if CD4 cell counts are high. During treatment interruption if teh counts remain high and the viral load at the low end, most would hold back on restarting therapy.

Lastly, you need to be tested for HIV both with an antibody and viral load as you may be acutely infected yourself if you have had sex with your boyfriend in the last several weeks.

Keep us posted.

DW