Academy Exchange

Hi Everyone! 

I inherited a patient recently who has had a series of HIV tests that have been borderline while on PrEP. I believe the initial tests may have happened too early for a confirmatory diagnosis. Here is the timeline:  

• Patient had been taking PrEP intermittently since 2017.
• Last negative HIV test was April 6, 2021. 
• 3-month follow-up July 7, 2021 was an indeterminate results (HIV1/2 indeterminate, p24 neg), as were the two subsequent tests: August 26 and October 13. 
• October 27, VL was 43 and was advised to abstain from sex for 2 weeks and to stop PrEP immediately (he had already not been using it since September as he had not been active). The patient had mentioned to the previous provider they were using PrEP daily throughout the 2021 summer without missed doses.  
• Repeat VL 127 November 24, 2021
• HIV test positive on December 1, 2021 (HIV-1)
• Repeat VL non-detectable on January 11, 2022
• Was started on Biktarvy January 22, 2022

I inherited this patient in October of 2022 and am waiting for proviral DNA and HIV tropism tests to come back. Another HIV positive test (HIV-1) was on October 31, 2022 when I first had an appoitnment with the patient. 

With 2 positive HIV tests now, this patient's HIV diagnosis is very likely positive. Quite understandably, the patient has been very anxious about this diagnosis over the last 1.5 years given daily PrEP use at the time of the indeterminate results and the fluctuating low viral load. I was curious as to this community's thoughts on the timeline for this patient's diagnosis or any other testing I should look into. 

Thanks!

Sean Yaphe, MD, MPH
Family Medicine Physician, Clinique L'Actuel
Montreal, Quebec, Canada

Hi Sean,

Yeah.  Diagnosing HIV infection in someone taking PrEP can be challenging.  If this person acquired HIV while adherence was suboptimal, the viral load may be low or even suppressed for a while if he or she continues taking PrEP.   Eventually, the level of viremia will increase when resistant virus emerges.  So, with the indeterminate results (and then positive result 12/21) and subsequent low level viremia,I do think your patient likely has HIV infection.  I believe fully suppressive therapy is indicated, as you are doing.  Assuming the patient was on Truvada or Descovy for PrEP, look for the presence of the M184V and K65R mutations on the proviral DNA assay.   Thanks!

Hi Everyone! 

I inherited a patient recently who has had a series of HIV tests that have been borderline while on PrEP. I believe the initial tests may have happened too early for a confirmatory diagnosis. Here is the timeline:  

• Patient had been taking PrEP intermittently since 2017.
• Last negative HIV test was April 6, 2021. 
• 3-month follow-up July 7, 2021 was an indeterminate results (HIV1/2 indeterminate, p24 neg), as were the two subsequent tests: August 26 and October 13. 
• October 27, VL was 43 and was advised to abstain from sex for 2 weeks and to stop PrEP immediately (he had already not been using it since September as he had not been active). The patient had mentioned to the previous provider they were using PrEP daily throughout the 2021 summer without missed doses.  
• Repeat VL 127 November 24, 2021
• HIV test positive on December 1, 2021 (HIV-1)
• Repeat VL non-detectable on January 11, 2022
• Was started on Biktarvy January 22, 2022

I inherited this patient in October of 2022 and am waiting for proviral DNA and HIV tropism tests to come back. Another HIV positive test (HIV-1) was on October 31, 2022 when I first had an appoitnment with the patient. 

With 2 positive HIV tests now, this patient's HIV diagnosis is very likely positive. Quite understandably, the patient has been very anxious about this diagnosis over the last 1.5 years given daily PrEP use at the time of the indeterminate results and the fluctuating low viral load. I was curious as to this community's thoughts on the timeline for this patient's diagnosis or any other testing I should look into. 

Thanks!

Sean Yaphe, MD, MPH
Family Medicine Physician, Clinique L'Actuel
Montreal, Quebec, Canada