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Should I Continue With Antiretroviral Drugs And Get A Repeat HIV Test?

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Posted on Fri, 2 May 2014
Question: hello Doctor , I m indian and leave in Delhi. I had a low risk exposure (protected sex with a CSW) on 18th Feb. after 24 days i felt worry of HIV (no symptom). I went to a Doctor (MD in Medicine and sexology). Doctor took blood sample and went for complete and expansive STD package ( HSV1/2, CD4, CD8, CD3, T cell and HIV1/2 test by fully automatic 4th generation western blot architecture. All came out negative and Ok. Still i was worried and asked doctor for HIV 1/2 and P24 combo (CMIA) at 44 days. instead of that he went for PCR RNA HIV and repeated the same western blot HIV test. Western blot test came all negative again at 44 days but PCR RNA TEST GAVE 225 COPIES/ML. looking at high possibility of false positive result in PCR test. it was not conclusive as CDC guidelines says a positive PCR RNA TEST SHOULD BE CONFIRMED BY antibody test only. For safety Dr. starts anti drugs propelix TEEVIR (Tenofovir Disofroxil fumarale/ Emtricitabine and Elavirenz 300 mg/ 200mg / 600 mg) one tab a day. I was too confused and today at 47 days post exposure I went for a HIV 1/2 & P24 Combo test in Dr. Lal Path Lab a renowned Lab in INdia, which gives index value of 0.1 and non reactive. now i am most confused as 47 days result of combo test should be highly accurate. and PCR test result may be false possitive. NOw My tests ar as follows: -4th generation western blot architecure at 24 days - all negative -4th generation western blot architecure at 44 days - all negative - PCR RNA at 44 days - Positive with 225 copies/ml. - HIV 1/2 & P24 Combo (CMIA) at 47 Days - non reactive index-0.1 my question are as follows: 1)Now should I continue with the anti drugs mentioned above or weight for result of 90 days HIV antibody test. My Dr. sugestted to take the tab for safety purpose looking at the PCR result. I have started the medicine from yesterday. 2) if i continue taking medicine and 90 days HIV 1/2 & P24 Combo (CMIA) negative results can be conclusive. is there any case that I am taking anti drugs and for that the 90 days result may come negative even though possibilty of positive result without medicine. Sorry for the long description. please help. I am becoming helpless, worry and sleepless and i have already spent a lot for this confusion.
doctor
Answered by Dr. Dr. Kakkar (51 minutes later)
Brief Answer: HIV testing Detailed Answer: Hi. I am Dr. Kakkar. I have gone through your query and I have understood it. A positive PCR RNA does prove that you are infected with HIV, but the guideline is that it should be confirmed with a antibody test to document subsequent seroconversion. Negative antibody tests at day 24 and day 44 can be explained by window period, i.e the time after infection when it can be detected by the test ( which is approximately 3 months for antibody based tests after infection/the time required for seroconversion). Regarding HIV combo test: The combo test for hiv tests for both HIV antibodies as well as p24 antigen. This HIV test can detect the virus from 28 days after infection and is called a "Duo" test because it combines an antibody test for the HIV antibody 1 & 2 strains of the virus, with an antigen test for the P 24 antigen. During the first few weeks after someone becomes infected with HIV, only P 24 (Antigen) is detectable in the blood. So the antigen is the first marker of HIV being present. So the HIV DUO test can detect an infection before the antibody test on its own can, it is used for diagnosing HIV much earlier in the course of infection. The test, is considered 99.8% accurate at 28 days, this accuracy increases to 99.9% at 90 days after any potential contact. P24 antigen becomes negative after seroconversion and the p24 antigen disappears rapidly. Therefore a negative result needs to be confirmed with a second test after 90 days, if the exposure is less than 3 months ago. I think you should continue with antiretroviral drugs and get a repeat test which can document seroconversion (antibody testing with western blot or elisa). The aim of treatment at this point of time, is to reduce the risk of further transmission because this is the period when HIV is most infectious when antibodies to it has not appeared in the serum. regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Dr. Kakkar (3 hours later)
Hl doctor sir Yes I am continuing with the medicine. I also want to know that is the medicine has no side effect, if any possibility of negative result. What is the possibility of false positive PCR result. Looking at the negative result of combo test at 47 days is highly accuratre Is it normal after 44days PCR test gives so less load in the case of infection. What is the chance of my getting negative. I have gone through the.body.com such cases happened I.e positive PCR test followed by series of negative antibody antigen test including at 90 days.
doctor
Answered by Dr. Dr. Kakkar (16 hours later)
Brief Answer: HIV tests Detailed Answer: Hi. Antiretroviral drugs are not without side effects Adverse effevts of Emtricitabine: -Headache, nausea, insomnia -Hyperpigmentation of palms and soles Adverse effects of Tenofovir: -Flatulence, nausea, diarrhea, abdominal discomfort -Renal insufficiency Adverse effects of Efavirenz: -Neuropsychiatric side effects:Abnormal dreams, drowsiness, dizziness, confusion, Mood changes -Elevations in liver function tests -Hyperlipidemia PCR is highly accurate. As I mentioned before that, P24 antigen becomes negative after seroconversion and the p24 antigen disappears rapidly. Therefore a negative P24 HIV combo test at day 47 needs to be repeated at day 90, if the exposure is less than 3 months ago. An HIV infected individual can lead an almost normal life, specially after the advent of HAART(Highly active antiretroviral therapy) but i am not aware of any such case which has become negative by this therapy OR a false postitive PCR. PCR is highly accurate and is mainly used to monitor response to therapy, rather than using it for screening. regards take care
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Dr. Kakkar (9 hours later)
Hi. thanx. you have not told that Is it normal after 44 days post exposure PCR RNA test gives so less load in the case of infection. please advise me doctor because i guess this drug may harm other organs too as per adverse effect explain by you. Doctor told me to take this for one month only.
doctor
Answered by Dr. Dr. Kakkar (38 minutes later)
Brief Answer: HIV test Detailed Answer: Hi. A low viral load means HIV may not be actively reproducing and the disease may progress more slowly. A low viral load is between 20 and 500 copies. However, what you want is an undetectable viral load. If your HIV viral load can't be detected, this does not mean you are cured. For most patients, the goal of treatment is to reach an undetectable viral load, which is currently defined as less than 20 copies. Yes, you can take it for 1 month only because actually the guideline is not to treat just because you are infected with HIV. Some doctors give it for an initial one month to decrease the HIV replication before any detectable antibody appears in the blood, which may delay progression of disease. There is a specific guideline to start ART: -As a priority, ART should be initiated in all individuals with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and individuals with CD4 count ≤350 cells/cu.mm. -ART should be initiated in all individuals with HIV with CD4 count >350 cells/cu.mm and ≤ 500 cells/cu.mm regardless of WHO clinical stage. Not all patients have all the side effects. Side effects are enumerated to educate the patient that they may have the following side effects. It does'nt guarantee that the side effects will indeed occur, specially when you are going to take the treatment for just one month. regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Dr. Kakkar (2 days later)
Hi Doctor, I am again writing because I am worry taht I may not know my actual HIV Status ever. After taking ART for one month the viral load may become undetectable and that time 90 days will be completed and my 90 days antibody test will definitely be negative. I was so worry and I am not able to believe that I am HIV positive. so I Have again taken a PCR RNA quantification test from another Lab i.e Dr. Lal Path Lab, New Delhi and it came out target not detected means HIV-1 Virus RNA not found in blood sample. the test name is HIV-1 RNA quantitative real time PCR test @ ( real time PCR using Cobas Ampliprep & Taqman.). the lower limit of detection is 20 copies/ml. I am now more confused.I have shown the report to my doctor. he is telling that it may be due to taking 3 days of ART or he do not have much faith on Lab set up of Dr. Lal path lab for this type of test.He is still insisting to continue with ART. this time he changes ART to Recovir EM as i was not feeling well with earlier ART. He told after one month of ART he will take the PCR test again in the same Lab at XXXXXXX Mumbai and then he can conclude. This Dr. is not my regular Doctor and I met him only to diagnosis the HIV status. I never knew him before. Now I have started to feel that I may be fallen under false positive for ever and i will never actually know my actual status. Now my test summary is as follows: - 44 th days PCR from a Lab Called Infexn at XXXXXXX mumbai sample received at Lab one day after collection from New Delhi. result 225 copies/ml. - 46th day -ART taken after receiving the report. - 47th day -ART taken - 48th day -ART taken - 49 th day - ART not taken as i was not feeling well. -50 th day PCR RNA in Dr, Lal , New delhi- result target not detected. Now I need Help from you my questions are as follows: 1) Is this negative PCR result from Dr. Lal Path Lab, New Delhi is due to taking only 3 days of ART. 2) Can PCR RNA test from Dr. Lal Path lab be false negative. 3) should I still continue with the ART (Recovir EM) 4) or should I wait for 90 days antibody test for conclusion. other wise with ART the antibody test may not be properly conclusive and documented. 5) If the ART taken by a HIV negative person, will there be any effect in CD4, CD8 or CD3 count or any other health problem. Thanks and expect pointwise clear sugestions.
doctor
Answered by Dr. Dr. Kakkar (55 minutes later)
Brief Answer: Wait till 90 days test to look for seroconversion Detailed Answer: Hi. 1) Recent negative RT PCR from dr. lal path lab, which is a very reliable lab, has really confused the whole scenario. 2) Theoretically, it could be false negative because you are taking ART treatment and the viral load is supposed to fall on treatment. 3) I think you should just wait for the antibody tests at 90 days. A negative antibody test at 90 days would be conclusive. 4) However, continuing with the treatment will anyways not affect seroconversion. A test at 90 days would be conclusive, even with or without treatment. 5) No ART does'nt affect CD4 , CD 8 or CD 3 cell count on its own Treatment is not really indicated in you case since the WHO guidelines suggests that a person should be treated only if he or she has advanced HIV disease or if the CD4 cell count is ≤350 cells/cu.mm. So in my view you really don't need to be treated with ART at this stage, more so because you don't even have any clinical symptoms yet suggestive of HIV. If I was the treating doctor I would have waited for your 90 days test report to detect seroconversion if any. If it is positive, then RT PCR would determine the viral load, which in turn would guide further treatment. I hope this answers your query. regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Dr. Kakkar (29 minutes later)
Hi Thanx doctor Only three days ART can reduce all 225 copies RNA. After three days ART I stopped for one day and then PCR RNA TEST TAKEN from Lal Path Lab Thanx
doctor
Answered by Dr. Dr. Kakkar (7 minutes later)
Brief Answer: No choice but to wait Detailed Answer: Hi. The best scenario would be test for seroconversion if any at 90 days, to be absolutely sure. regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dr. Kakkar (9 hours later)
HI During taking ART MY LIP Was drying and swelling. While asking Doctor he was telling that your immune system is fighting the virus. That is why you are getting reaction from ART. Is it true. Is Drying and swelling the lip and slight normal sore on lip is symptom of Hiv. I do not have other symptom Thanks
doctor
Answered by Dr. Dr. Kakkar (3 hours later)
Brief Answer: Upload a picture Detailed Answer: Hi. I would like to gather more information from you in order to be able to help you better. --Did you ever develop sores on your lip ever before? --Can you upload a clear picture of the affected area? Grouped fluid filled vesicles and subsequently rupturing to form erosions/sores, can be due to herpes labialis. I would like to rule out herpes, if you could please upload a clear picture of the affected area/sores. Another possibility is of Aphthous ulcer. These side effects(sore) and drying/ swelling of lips are not specific to ART and can happen in otherwise normal individuals as well, but the significant point in your case is that oral/labial sores, that come and go, are part of the AIDS symptom complex. You could use an antibacterial gel twice or thrice daily for the sores, hexidine gel is available OTC. regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dr. Kakkar (28 hours later)
Hi Doctor, There is no significant sore on lip, gum or inside mouth. I have misguided you sir. those are little crack on the dry lip. I often suffer with this even in summer season also. It was seen during taking the ART with slight swell. I will upload the picture later.
doctor
Answered by Dr. Dr. Kakkar (2 hours later)
Brief Answer: Cheilitis Detailed Answer: Hi. Ok. That's good. A regular lip balm for a few days would suffice for cheilitis. regards
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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Dr. Kakkar

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Should I Continue With Antiretroviral Drugs And Get A Repeat HIV Test?

Brief Answer: HIV testing Detailed Answer: Hi. I am Dr. Kakkar. I have gone through your query and I have understood it. A positive PCR RNA does prove that you are infected with HIV, but the guideline is that it should be confirmed with a antibody test to document subsequent seroconversion. Negative antibody tests at day 24 and day 44 can be explained by window period, i.e the time after infection when it can be detected by the test ( which is approximately 3 months for antibody based tests after infection/the time required for seroconversion). Regarding HIV combo test: The combo test for hiv tests for both HIV antibodies as well as p24 antigen. This HIV test can detect the virus from 28 days after infection and is called a "Duo" test because it combines an antibody test for the HIV antibody 1 & 2 strains of the virus, with an antigen test for the P 24 antigen. During the first few weeks after someone becomes infected with HIV, only P 24 (Antigen) is detectable in the blood. So the antigen is the first marker of HIV being present. So the HIV DUO test can detect an infection before the antibody test on its own can, it is used for diagnosing HIV much earlier in the course of infection. The test, is considered 99.8% accurate at 28 days, this accuracy increases to 99.9% at 90 days after any potential contact. P24 antigen becomes negative after seroconversion and the p24 antigen disappears rapidly. Therefore a negative result needs to be confirmed with a second test after 90 days, if the exposure is less than 3 months ago. I think you should continue with antiretroviral drugs and get a repeat test which can document seroconversion (antibody testing with western blot or elisa). The aim of treatment at this point of time, is to reduce the risk of further transmission because this is the period when HIV is most infectious when antibodies to it has not appeared in the serum. regards