Academy Exchange

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik

Dear Michael,

If the CD4+ T cells are 34% of total lymphocytes and not 34 cells/mm3, she may well be an elite controller.

Generally, I have followed patients like this for at least 1 year and commonly longer, to make the determination that they are an 

elite controller, as HIV RNA PCR assays are not always 100% reliable. It would also be wise to be assured that she is not taking any ARVs as well, although this can be challenging if she is taking them surreptitiously. It is never bad news to deliver to a patient, if she is in fact one of the ~1% of HIV + persons whose immune system are able to control HIV.

The decision to treat HIV controllers has been addressed by a few exploratory clinical trials and several recent reviews: 

1) Antiretroviral Treatment for HIV Elite Controllers? - PMC

2) HIV controllers: to treat or not to treat? Is that the right question? - The Lancet HIV

3) Clinical outcomes and antiretroviral therapy in 'elite' controllers: a review of the literature - PMC

4) Should HIV controllers take HIV treatment? | aidsmap 

Most of these recommend starting ART if CD4+ T cells decline, HIV RNA increases or markers of inflammation are high.

I recommend establishing the diagnosis first with continued follow-up and discuss ART with her.

David

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik

Thanks for you answers and comments !  the 34 in her abs CD 4 helper number and her actu % CD 4 Pos. Lymph is 8.6%.  I honestly believe she has not taken any ART medications as I believe she is still a little in shock with the diagnosis.  I think what worries me is the CD4 count but a normal total WBC.  Will be interesting to see if the endocrinologist has any comment concering Hashimotos and HIV ?

Dear Michael,

If the CD4+ T cells are 34% of total lymphocytes and not 34 cells/mm3, she may well be an elite controller.

Generally, I have followed patients like this for at least 1 year and commonly longer, to make the determination that they are an 

elite controller, as HIV RNA PCR assays are not always 100% reliable. It would also be wise to be assured that she is not taking any ARVs as well, although this can be challenging if she is taking them surreptitiously. It is never bad news to deliver to a patient, if she is in fact one of the ~1% of HIV + persons whose immune system are able to control HIV.

The decision to treat HIV controllers has been addressed by a few exploratory clinical trials and several recent reviews: 

1) Antiretroviral Treatment for HIV Elite Controllers? - PMC

2) HIV controllers: to treat or not to treat? Is that the right question? - The Lancet HIV

3) Clinical outcomes and antiretroviral therapy in 'elite' controllers: a review of the literature - PMC

4) Should HIV controllers take HIV treatment? | aidsmap 

Most of these recommend starting ART if CD4+ T cells decline, HIV RNA increases or markers of inflammation are high.

I recommend establishing the diagnosis first with continued follow-up and discuss ART with her.

David

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik

If 34 is truly the correct absolute CD4 count, that would be quite unusual for some one who might be an elite controller.  Obviously you would want to start PJP prophylaxis and check a serum cryptococcal antigen. I would start anti retroviral therapy now unless there is a good reason not to.  We would assume that CD4 suppression is being caused by high levels of immune system activation and inflammation.  Not sure if Hashimoto's can cause or affect this.  You also might want to recheck the T cell panel. I have had a few cases over my career where the initial values did not make sense and changed significantly on recheck.  Let us know what happens!

Thanks for you answers and comments !  the 34 in her abs CD 4 helper number and her actu % CD 4 Pos. Lymph is 8.6%.  I honestly believe she has not taken any ART medications as I believe she is still a little in shock with the diagnosis.  I think what worries me is the CD4 count but a normal total WBC.  Will be interesting to see if the endocrinologist has any comment concering Hashimotos and HIV ?

Dear Michael,

If the CD4+ T cells are 34% of total lymphocytes and not 34 cells/mm3, she may well be an elite controller.

Generally, I have followed patients like this for at least 1 year and commonly longer, to make the determination that they are an 

elite controller, as HIV RNA PCR assays are not always 100% reliable. It would also be wise to be assured that she is not taking any ARVs as well, although this can be challenging if she is taking them surreptitiously. It is never bad news to deliver to a patient, if she is in fact one of the ~1% of HIV + persons whose immune system are able to control HIV.

The decision to treat HIV controllers has been addressed by a few exploratory clinical trials and several recent reviews: 

1) Antiretroviral Treatment for HIV Elite Controllers? - PMC

2) HIV controllers: to treat or not to treat? Is that the right question? - The Lancet HIV

3) Clinical outcomes and antiretroviral therapy in 'elite' controllers: a review of the literature - PMC

4) Should HIV controllers take HIV treatment? | aidsmap 

Most of these recommend starting ART if CD4+ T cells decline, HIV RNA increases or markers of inflammation are high.

I recommend establishing the diagnosis first with continued follow-up and discuss ART with her.

David

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik

If 34 is truly the correct absolute CD4 count, that would be quite unusual for some one who might be an elite controller.  Obviously you would want to start PJP prophylaxis and check a serum cryptococcal antigen. I would start anti retroviral therapy now unless there is a good reason not to.  We would assume that CD4 suppression is being caused by high levels of immune system activation and inflammation.  Not sure if Hashimoto's can cause or affect this.  You also might want to recheck the T cell panel. I have had a few cases over my career where the initial values did not make sense and changed significantly on recheck.  Let us know what happens!

Thanks for you answers and comments !  the 34 in her abs CD 4 helper number and her actu % CD 4 Pos. Lymph is 8.6%.  I honestly believe she has not taken any ART medications as I believe she is still a little in shock with the diagnosis.  I think what worries me is the CD4 count but a normal total WBC.  Will be interesting to see if the endocrinologist has any comment concering Hashimotos and HIV ?

Dear Michael,

If the CD4+ T cells are 34% of total lymphocytes and not 34 cells/mm3, she may well be an elite controller.

Generally, I have followed patients like this for at least 1 year and commonly longer, to make the determination that they are an 

elite controller, as HIV RNA PCR assays are not always 100% reliable. It would also be wise to be assured that she is not taking any ARVs as well, although this can be challenging if she is taking them surreptitiously. It is never bad news to deliver to a patient, if she is in fact one of the ~1% of HIV + persons whose immune system are able to control HIV.

The decision to treat HIV controllers has been addressed by a few exploratory clinical trials and several recent reviews: 

1) Antiretroviral Treatment for HIV Elite Controllers? - PMC

2) HIV controllers: to treat or not to treat? Is that the right question? - The Lancet HIV

3) Clinical outcomes and antiretroviral therapy in 'elite' controllers: a review of the literature - PMC

4) Should HIV controllers take HIV treatment? | aidsmap 

Most of these recommend starting ART if CD4+ T cells decline, HIV RNA increases or markers of inflammation are high.

I recommend establishing the diagnosis first with continued follow-up and discuss ART with her.

David

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik

Thanks for you answers and comments !  the 34 in her abs CD 4 helper number and her actu % CD 4 Pos. Lymph is 8.6%.  I honestly believe she has not taken any ART medications as I believe she is still a little in shock with the diagnosis.  I think what worries me is the CD4 count but a normal total WBC.  Will be interesting to see if the endocrinologist has any comment concering Hashimotos and HIV ?

Dear Michael,

If the CD4+ T cells are 34% of total lymphocytes and not 34 cells/mm3, she may well be an elite controller.

Generally, I have followed patients like this for at least 1 year and commonly longer, to make the determination that they are an 

elite controller, as HIV RNA PCR assays are not always 100% reliable. It would also be wise to be assured that she is not taking any ARVs as well, although this can be challenging if she is taking them surreptitiously. It is never bad news to deliver to a patient, if she is in fact one of the ~1% of HIV + persons whose immune system are able to control HIV.

The decision to treat HIV controllers has been addressed by a few exploratory clinical trials and several recent reviews: 

1) Antiretroviral Treatment for HIV Elite Controllers? - PMC

2) HIV controllers: to treat or not to treat? Is that the right question? - The Lancet HIV

3) Clinical outcomes and antiretroviral therapy in 'elite' controllers: a review of the literature - PMC

4) Should HIV controllers take HIV treatment? | aidsmap 

Most of these recommend starting ART if CD4+ T cells decline, HIV RNA increases or markers of inflammation are high.

I recommend establishing the diagnosis first with continued follow-up and discuss ART with her.

David

Recommendations or advise ?

Have newly established patient..  44yo female, recent diagnosis:

HIV 1/2 Ab = HIV 1 Ab = positive 

HIV Ab/p24 Ag = preliminary reactive.  

HIV-1 RNA by PCR = <20

CD4 =34

WBC =7.2

TSH= 43.6 (has been referred to endocrinology, has history of Hashimoto)

Patient state no sexual relations in over 10years.

Question is this an elite controller or is the Hashimotos affecting the lab results ??  Also shoud ART be started ??

Thanks ALL, little confused here  dr dorcik