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Newly Diagnosed and HIV Viral Load Undetectable? Consider Drug Testing for HIV Meds

Summary and Comment |
November 13, 2013

Newly Diagnosed and HIV Viral Load Undetectable? Consider Drug Testing for HIV Meds

  1. Paul E. Sax, MD

In a clinical trial that included presumably untreated people with HIV infection, 86% of those with viral loads <1000 copies/mL were actually taking antiretroviral drugs.

  1. Paul E. Sax, MD

Both in HIV clinical trials and in practice, identification of newly diagnosed individuals frequently relies on self-report — a patient tells you he or she has never tested HIV-positive before. An analysis from a recent HIV-prevention study suggests that some of those reporting newly diagnosed HIV infection are in fact already receiving HIV treatment.

The HIV Prevention Trials Network 061 study evaluated the feasibility of a multicomponent intervention to reduce HIV incidence among black men who have sex with men in the U.S. Individuals with HIV infection were eligible if they were not on treatment, based on self-report of being newly diagnosed or previously diagnosed but not in care. Among the 155 participants who reported a new diagnosis, 83 had viral loads <1000/mL. All 83 underwent blood testing for antiretroviral agents, and 71 (85.5%) of them had at least one drug detected. Of the 68 participants with viral loads <400, 63 (92.6%) had such drugs detected.

Comment

This interesting report certainly shows that the secondary gain from clinical trial participation may be sufficient to lead individuals to hide a previous diagnosis and receipt of treatment. Indeed, similar results were reported from HPTN 052, in which approximately half the “treatment-naive” participants with HIV infection who had an undetectable viral load were in fact already receiving antiretroviral therapy (J Infect Dis 2013; 208:1624).

Whether such nondisclosure would occur to the same extent in clinical practice is unclear. When encountering a newly diagnosed individual with an undetectable viral load, providers should repeat HIV-antibody testing to exclude a false-positive result, a laboratory error, or factitious HIV infection. Those who have confirmed positive results and undetectable HIV viral loads are either HIV “controllers” or already receiving HIV treatment and not reporting this to their providers. In select circumstances, clinicians —not just clinical researchers — may wish to test for detectable antiretroviral agents in patients with undetectable viral loads who say they are not receiving treatment.

  • Disclosures for Paul E. Sax, MD at time of publication Consultant / Advisory board Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Janssen; Merck Grant / research support NIH; Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Merck Editorial boards Medscape; UpToDate Leadership positions in professional societies Mass ID Society (Vice President)

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