Teak and Chris

What actually causes a HIV positive person's viral load to be undetectable <48 copies?  In other words, the literature states that the virus enters the body, multiplies fairly quickly over days and certainly over the first couple-few weeks.  Then your body reacts by producing antibodies.  It is my understanding that antibodies are created to fight the HIV virus just like antibodies that are produced to fight everyday bugs.  I guess the difference with HIV is it continues to thrive in the body.

The reason I ask is because I know there is a lot of discussion around undetectable viral loads.  Clearly it is possible for someone to have an undetecable viral load and still have HIV.  However, if this is the case, would it make sense that their body would have produced detectable antibodies to squash the virus to undetectable levels?  If this isn't the case, then what does control the virus so well in some people that makes it undetectable?  By the way, I'm referring to acute hiv or early stages.  I understand the medical therapies to treat HIV can also help reduce the viral load.  I'm just not sure how someone could have an undetectable viral load when they are symptomatic after a couple weeks-2 mos post exposure.  How does a HIV pos person know if they didn't ever have a detectable viral load if their viral load in undetectable today.  It may have been high early on right?

Also, I know these tests are techinically not diagnostic tests.  Teak, I know you aren't a big fan for this reason.  Clearly there is some risk of false pos because the test is so sensitive and specificity is not 100% and the cost is high.  It just seems like there aren't many or any documented cases of false neg during acute hiv...maybe I'm wrong but I can't seem to find anything.

[Teak]

Yes, it is possible for one to have HIV and a undetectable VL without medication. Those folks are called "elite controllers." There are those that are LTNP that their VL stay very low but are still detectable and their CD4 stays within the normal range. I was a LTNP for 21 years without the need of medication. Then you have those of us that have an undetectable VL due to antiretroviral medications. How is it all known? It's known by continued monitoring testing, that is where your PCR tests come in to play. The majority of us that are HIV positive, have labs taken every three months. Not only for CD4,CD8, and viral load, but also for your CBC's to keep track of your liver enzymes. All antiretrovial medication is toxic to the liver some medication are more toxic to the liver than others. Not only does the medication cause increase of liver enzymes, but has a substantial effect on your cholesterol levels and triglyceride levels. This is why PCR testing is not a good or approved for diagnostic testing in early possibly infected HIV patients. Just because one has no detectable VL does not mean they are not infected with HIV. That is why we have antibody tests, once a test is positive and confirmed for HIV antibodies, there is no doubt that they are indeed infected.

[needhonesthelp]

Thanks Teak...this all makes sense to me.  Again I know this VL test really isn't indicated for diagnostic use.  So what you are saying is someone could have an undetectable viral load early on in the infection and still be positive.  Most likely this is due to them being an "elite" or LTNP.  I guess the only part that gets confusing is if their body controlled the virus to undetectable levels so quickly, does this mean that they would have detectable antibodies to HIV?  Aren't the antibodies the main reason the virus is undetectable?  I'm sure there are some other reasons too, but this is my understanding based on how other viruses funtion.  Take Hep B for example- someone gets infected, develops core antibodies, and if they develop surface antibodies they become immune...their body squashed the virus and they no longer test pos for the antigen.

The main question that lingers for me is simply does a negative VL and negative antibody test give conclusive evidence that someone is not infected.

[Teak]

Just because one has an undetectable VL does not mean they would have undetectable antibodies to HIV. They would definitely show HIV antibodies on their antibody tests.
It's not that one would have undetectable VL so quickly, it's that they never has a high VL or detectable VL at all. HBV has nothing in common with HIV. One can get acute HBV, get well and due to there antibody production never get HBV again. Then you have ones that have chronic HBV that never really get over it and their signs and symptoms do come back and they are always infectious. You can also get vaccinated for HBV and HAV, to prevent infection but HIV does not have a vaccination. As for a negative antibody test at 3 months or longer means you are indeed HIV negative. As for VL, there are other diseases that can cause a spike in your VL that has nothing to do with HIV. That is another reason VL tests are not recommended do diagnose HIV infection.  

[needhonesthelp]

In addition, I would imagine people produce different levels of antibodies to HIV.  Maybe elites and LTNP produce more antibodies and have a strong immune response which contributes to driving a VL down to undetectable levels.  If this was the case, I would think they would have very detectable antibodies early on and certainly by 3 mos.  

Maybe my thought process is off on this which is why I'm asking you.  

[needhonesthelp]

I hope I read your reply correctly.  You saying that if someone has an undetectable VL, they should definitely have HIV antibodies if they are indeed infected.  If both are neg then clearly they don't have HIV...

Also, I know HIV is very different than anything else including HBV.  Maybe that was a bad reference.  I'm just trying to make sure I fully understand how a VL test can be undetectable and yet someone can be infected.  It sounds like if this was the case, assuming a few weeks or more have passed, the person would definitely have antibodies which is why the VL is so low because the antibodies drive the VL to undet levels, right?

This is my final thought because I know I will exhaust you with more questions.  Thanks

[Teak]

Yes they do have antibodies that are detectable at 3 months like most others. As with all folks that test most will have a detectable antibody test at 6 weeks. Don't let the viral load levels and antibody levels confuse you. They are two totally different things. I'm not going to get into the reasons some people are "elite controlers" or "LTNP" it's just to in depth and studies are on going for the reasons.

[needhonesthelp]

As I read ur last response again you state that some may never have a VL at all even during the acute phase.  Is there research why this may be...does it point to rapid antibody production as the reason.  I just figure any other reason for squashing the virus before it takes off...could this means an antibody test would be pos early on 1-2 mos maybe...assuming the VL at this time was neg

[needhonesthelp]

I was typing while you responed...my bad.  I'm sure it is very complicated.  I will take all this info and make what I can with it.  

I guess the key takeaway is the elite and LTNP are rare.  They may not have detectable VL early in acute HIV or later stages because their immune response was so strong.  And they would definitely have detectable antibodies no later than 3 mos.  Of course, it almost makes sense that they would have antibodies well before 3 mos if they never had a VL and squashed the levels so quickly since antibodies contribute to control a virus.

Please correct me if any of this sounds incorrect.

[Teak]

What I actually said is, they either never had a viral load to begin with or never had a very high viral load at all.

[needhonesthelp]

The odd part about this is if they never had a VL to begin with, how does the body produce antibodies to a virus that exists with such low undetectable levels?  It seems like either they produce a lot of antibodies quickly and the VL is never detectable so they have definitely have antibodies or they the VL is so low from the beginning there could be a delayed response in producing antibodies.  Maybe it would take longer than 3 mos to produce antibodies if the virus is so darn low and the body doesn't react.

Does the research point to one or the other?  

[Teak]

The antibodies that one produces controlled the virus's replication. Without an overwhelming viral replication, there would be no detectable viral load. One shows a viral load when the viral replication is faster than the antibodies can control, hence the reason for antiretrovial medications for those that are not "elite controllers" or LTNP.

[needhonesthelp]

OK, thanks Teak.  So basically it does seem clear that if there is no VL this is due to the antibodies controlling the virus's ability to replicate.  An undet VL after a couple months past exposure should show antibodies if someone was infected...assuming the antibody test are newer generation and very sensitive.  Therefore, no VL and no antibodies must be very conclusive that the person doesn't have HIV.  The main reason for my sake is I had the VL test at 2 and 9 weeks...both <48c undet...and I had antibody tests at this time that were neg too...of course I had a 13 wk anti test too that was neg...I'm just trying to be 100% sure I'm neg...

[Teak]

You can't get anymore negative than that.

[needhonesthelp]

I hope you're right Teak.  You have put up with a lot of questions from me and I do appreciate it.  As I stated on this forum earlier, I'm married with 2 kids and my wife wants another.  She knows about my work exposure and thinks I need to chill out.  Everytime I think back to all my symptoms that I still experience today it just scares me.  I just worry about her health too...  If we try to have another baby I would never be able to live with myself if something bad happened regarding HIV or Hep C.  So far, tests look ok...but I guess I just hope I'm not some sort of statistical phenomenon.  Of course, my stupid fricking allergy test worries that we discussed are driving me nuts now too.  I know you probably think I'm wacked-out.  In reality, I'm a pretty normal guy that used to be a lot of fun.  I feel like my life revolves around worrying about my health all the time now.  I clearly need to find a way to stop this cycle.

[nonbeliever]

i know what you mean,i am a pretty normal guy that use to be alot of fun, and have had 4 neg test over 11 months and undetechable pcr rna down to 48 copies, i asked the same question as you about if there is not one there has to be the other, after 3 months. that would make sense, i think teak answered me back a couple of weeks. hope we both get back to being the fun loving guys.

[Teak]

There is help for those like you. Contact the mental health system in your area.

[needhelp629]

Our study has limitations. Eligible participants were only those whose HIV diagnosis occurred within the previous 12 months. The period during which the STARHS can detect recent infection is limited to a maximum of 200 days, thereby providing a narrow window during which recent infection can be defined. The Vironostika HIV-1 enzyme immunoassay test for detecting recent infection performs differently on non-B subtypes than on B subtypes.[13] In an analysis of the first 645 specimens in this study, however, only 1.6% were non-B subtypes.[14] Thus, we believe that the STARHS results in this study are unlikely to have been affected by differences in subtype. Because participants were recruited in a nonrandom fashion from clinics selected for their capacity to identify and recruit untreated HIV-infected patients whose HIV diagnosis was recent, selection bias may limit our ability to generalize the risk of new infections. Nevertheless, the sample was large and geographically and demographically diverse. In addition, the sampling method made it difficult to determine whether the factors associated with recent infection reflect a true risk for new infections or testing and care-seeking behavior. Thus, it is important to interpret the findings from this study in conjunction with results from other studies.

Our finding of recent infections in 20% of persons whose HIV diagnosis occurred within the past 12 months indicates that relatively few people receive their HIV diagnosis shortly after acquiring infection. Studies have demonstrated that persons who become aware of their HIV infection reduce risk behavior, and thus HIV transmission.[15,16] This highlights the need to expand HIV testing so that diagnoses of infected persons can be made early. Newer testing strategies, such as rapid tests, making HIV testing a routine part of medical care,[17] and RNA testing to detect acute HIV infection[18,19] may possibly be effective in this effort. Application of the STARHS to a larger population of persons with a new diagnosis of HIV infection is one method of identifying those populations in which HIV diagnoses are occurring late so that diagnostic and prevention efforts can be appropriately directed. Several laboratory methods to detect early HIV infection before and after seroconversion are available or under development and should allow for continued measurement of HIV incidence and characterization of persons with recent HIV infection.[20]

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[nonbeliever]

that is what i am trying now, cant think of anything else.

[needhonesthelp]

I did actually speak with someone after this incident initially happened and I got back a neg VL test at 2 wks...my doc said I neeeded to chill a little.  At that time, the lady I spoke to discussed that I clearly have OCD...no kidding.  She said stop replaying everything so much.  Well that is easier said than done.  I guess time will heal my worries.  I just still wonder if I need to be tested out to 6 mos to be 100% sure.  That is probably the one lingering problem I have right now...and I need to convince myself that it is very unlikely I was exposed to anything during my allergy test.

To Nonbeliever- I think testing neg out to 11 mos is more conclusive than anything else you have in your life right now.  Your body isn't all of a sudden going to produce antibodies past 6 mos...you'd be the first ever.  I hope you can get life back to normal too.

[Teak]

What did that have to do with this thread? Absolutely nothing.

[Teak]

Work on your OCD. You are HIV negative. You don't need any further testing.

[needhelp629]

Detection of HIV-1 infection in blood donors during the immunological window period using the nucleic acid-amplification technology.
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Individual nucleic acid-amplification testing (NAT) was recently recommended by Brazilian legislation and has been implemented at some blood banks in the city of São Paulo, Brazil, in an attempt to reduce the transfusion transmission of human immunodeficiency virus (HIV) and hepatitis C viruses. This screening test can identify donations made during the immunological window period before seroconversion. The impact of this technology in our blood donors and transfusion routine was studied. In all, 47 866 donations were tested from March 2004 until November 2005, according to Brazilian legislation, using two approved enzyme immunoassays for HIV antibodies and individual NAT. Supplemental tests included Western blot, p24 antigen detection and quantitative PCR-HIV-1. Among the donors screened, two (one first-time and one repeat donor) were non-reactive in enzyme immunoassays, with negative confirmatory p24 antigen and Western blot, but positive for HIV-1 NAT. Although serological analysis for HIV is a primary tool for diagnostic testing, the addition of NAT allowed for identification and prevention of component transfusion from two HIV-positive blood donations during an 18-month period. The screening of donors reduced the immunological window period, permitting the identification of very early stage HIV infections. In addition, this report also emphasized the fact that the risk of HIV transmission is not limited to the first-time donors.

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[needhonesthelp]

Teak, I wish I knew you better man...I mean it.  Hearing things from you is probably more therapeutic than a doc sometimes.  Hopefully you are who I think you are...filled with great knowledge and willing to share and be honest.

I know you have already stated that you don't think I was at risk during my allergy test.  I didn't initially mention the other concern I had while at the ENT doc office. While I was there I got scoped by the ENT doc because I do suffer from some heartburn.  I know they clean these scopes really well but when the docs assistant came in with the scope she did touch the end to clean the camera with a defogger.  Then the doc glides into my nose and throat w/ her hands.  I know my doc cleaned her hands well in front of me which hopefully means I'm fine but I don't know about the assistant.  I don't know why they don't use gloves...She could have touched something infectious too.  Is this another scenario of some risk or zero risk for HIV & Hep C?

Sorry for bringing this up.  I just want to clear my head entirely.  It is my last question I promise!  These darn incidents on Friday just bug me.

[Teak]

I'm sorry for laughing, but your concern is your OCD issues. Not HIV,not your allergy tests and in no way the scope job. See your doctor for some medication. It's really stupid to live your life like this when you don't have to.

[needhonesthelp]

I know it probably is funny to most people.  I'm not offended at all by you laughing.  I do need to get a grip of my life.

These incidents on Friday just seemed like bad form to me.  Heck the scope goes into my sinuses and down my throat.  If there was something infectious on it there would be an exposure because of it comes into contact w/ the mucosal membrane and any irritation that occurs, which there was some.

I'm sure they try to be safe and careful w/ their equipment.  It just seems like bad form to me because I work in the healthcare field.  The office is very nice, clean,etc.  I went to this office a year ago and had this done and never worried...this time I'm worried.  Are you sure there would be no risk?

[Teak]

I'm positive you didn't have a risk. You know, people without OCD don't think like you do, they tend to think rationale.

[needhonesthelp]

Maybe I am being irrational.  I can't just keep worrying about all the "what-ifs".  I guess I'm going to give this a rest for awhile and try to enjoy some of my day.

I will be doing my best to enjoy the Super Bowl tonight.

Take care Teak!

[Teak]

Maybe you're being irrational? You think? Go see your doc, get some medication and get on with your life.