Dear HIV Specialist:
I was infected about a year and a half ago and diagnosed about 11 months ago. Upon diagnosis I had positive ELISA and then indeterminate Western Blot. Then, I had a positive ELISA and Western Blot on blood draw. In August, October, January, and April I had an undetectable viral load with a CD4 count above 800 each time. Last week, I visited my doctor again for my final hepatitis vaccinations and my normal three-month check up. My CD4 count was above 1,100 and my viral load came back at 100. Naturally, I have not taken any HIV medications yet. I have read some about “long-term non-progressors” and am obviously hoping to be in this category as time marches forward. What is the current medical opinion on LTNP and what can I expect?
Signed, Hoping
Dear Hoping:
I am happy for you. I have had many patients I have followed over the last 20 years with similar numbers and some have been in the same category as you ever since we’ve had the HIV test in the mid-1980s—the viral load is undetectable or very low, less than 1,000 occasionally or always undetectable, and their CD4 is above 500.
We keep following these patients and making sure that there isn’t a decline in CD4s or a rise in viral load. I sometimes let them come in every six months when their body vs. virus war has shown that the body is winning based on the last three blood tests.
We think the ability for the immune system to stay so healthy is due to the inheritance of a protective mutation, making it difficult for the virus to enter the cell. This has been estimated to be in around 7% of Europeans. I have worked mainly with non-European patients so I have seen it mainly in African descendents who must have had a European ancestor in the mix.
How did this happen? A great many Europeans died from three major plagues: the flu, smallpox, and the bubonic plague; some of the survivors of these plagues survived because they had a genetic mutation that was protective, and one of these mutations may be the one helping you.
For example, Africans had malaria and those with the sickle cell mutation seem to not get as sick from malaria.
Another example of evolution in action: If I spray a field of 1 million mosquitoes with DDT, then maybe only 1 in 10,000 will survive due to not getting any or enough spray, or having a protective mutation, leaving 100 alive and 999,900 dead. These very few survivors will have many offspring over the next few generations reaching 1 million again with a much larger percentage having the protective mutation.
My recommendations for you are to monitor your numbers, have periodic exams like HIV-negative people, and practice the healthy habits you know you should!
Daniel Pearce, D.O., AAHIVS
Associate Professor of Internal Medicine
Chief, Division of Hospital and General Internal Medicine
Medical Director of HIV Services
Western University of Health Sciences
College of Osteopathic Medicine of the Pacific
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Dear HIV Specialist:
How many different types of tests are there to detect HIV viral load? My doctor told me there is only one available, but reading online it seems like there are more.
My viral load has been checked twice since being diagnosed as being HIV-positive, but my viral load has come back twice as being undetectable (less than 48 copies). From my sexual history it was concluded that I was infected almost two years ago. My CD4 count is in the high 400s.
Is this a normal situation, after two years of infection to have a high CD4 [count] and an undetectable viral load without being on any medication?
Signed, Testing
Dear Testing:
You are correct that there are different tests to measure the HIV-1 viral load.
Viral load refers to the number of “copies” of free virus in the blood and is used as a guide for when to start antiretroviral treatment and as a monitor of your response to therapy. There are three different assays (or tests) from three different categories available for viral load, also called quantitative HIV-1 RNA, tests:
- RT-PCR or reverse transcriptase polymerase chain reaction (PCR)
- bDNA or branched chain DNA
- Nucleic acid sequence based amplification assay (NASBA)
The bDNA assay (Versant v.3.0) uses a different technique of viral probes that are linked to another molecule resulting in a chemical light reaction. This assay measures from 75 to 500,000 copies/mL. The last assay, NASBA (NucliSens HIV-1 QT), measures from 40-1600 copies/mL and can be used to measure virus in other body fluids.
When measuring your viral load, it is important to use the same type of assay from one measurement to the next to be able to compare results. The goal of HIV therapy is to control the replication, or growth, of virus and get the viral load in your blood to levels that are “undetectable.” When the viral load is undetectable or below the lowest number of a particular test, you can still have HIV stored in other parts of your body, however.
Your situation, where the viral load is undetectable after two years without treatment, is fortunate but not that common. Most persons infected with HIV-1 will have some level of virus in their blood. There are individuals who seem to control their HIV virus without therapy. There are research studies to examine what factors, genetic or immune-related, enable the virus to be held in check by these “elite controllers.”
As for the CD4 count, individuals can lose a different amount of cells every year depending on the level of immune activation. The CD4 count on any given test can be influenced by many factors, from an intercurrent illness to time of day.
Ellen Tedaldi, M.D., AAHIVS
Temple University Hospital
Philadelphia, PA