Thanks, Lealah. I'm not completely convinced either, which is why I'd want to see all these labs repeated off therapy. And if the results are still equivocal, he may need evaluation by someone who studies elite controllers and can do tests that aren't available commercially. However, I've seen a few false HIV diagnoses over the years, usually based on a positive screening test and a very low viral load. (Lawyers sometimes ended up getting involved!)
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Joel Gallant, MD, MPH
Johns Hopkins University
Baltimore, MD
AXCES Research Group
Santa Fe, NM
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Original Message:
Sent: 07-10-2025 18:04
From: Lealah Pollock
Subject: Prescribe PrEP or treat?
Hi Joel.
I think the only concern I have would be that those two HIV DNA PCRs were done after what sounds like at least a couple of months of treatment, so should be definitely taken with a grain of salt. He's had low level viremia twice off of meds. I agree that repeating HIV RNA, HIV DNA (+/- HIV DNA archive resistance testing, which would definitely be proviral cell associated DNA), and Western Blot while off meds would be helpful, but I am not convinced that this is a false positive.
Best,
Lealah
Original Message:
Sent: 7/10/2025 5:04:00 PM
From: Joel Gallant
Subject: RE: Prescribe PrEP or treat?
Rebecca,
The question is whether he is an elite controller or was incorrectly diagnosed with HIV based on a false-positive serology and a very low viral load (which can happen in people who aren't infected). I wouldn't start him on PrEP until this has been completely cleared up. Many people with false positive diagnoses have no clear risk factors for HIV. That's presumably not the case with your patient, since he's asking for PrEP. But arguing strongly for a false positive diagnosis are the negative HIV DNA PCRs. He's probably not infected, and I'm probably being overcautious, but I'd want to make absolutely certain, so I would probably repeat the serology, this time using the old-fashioned ELISA and Western blot method. (The WB should be negative or indeterminate, usually with an isolated p24 antigen). I would also repeat the VL and HIV proviral DNA PCR, which should be negative again. If the results all come back negative, then he's not infected and PrEP can be prescribed.
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Joel Gallant, MD, MPH
Johns Hopkins University
Baltimore, MD
AXCES Research Group
Santa Fe, NM
Original Message:
Sent: 07-10-2025 14:50
From: Rebecca Kim
Subject: Prescribe PrEP or treat?
Hi all,
I'm seeing a 32M with no significant medical history. In 5/2021 and 10/2022 he had negative 4th gen testing.
In 8/2023 has +HIV 1 Ab x2. VL is 30.
He is started on Biktarvy and VL drops to <20. He doesn't take any other meds and opts to switch to Cabenuva. Gets 1 dose. Then because his initial VL was so low gets DNA checked and it's negative x2.
1/2025 all meds are stopped. Partly due to insurance lapse.
He's coming in now because he wants to go on PrEP. VL now is 50.
I'm not exactly sure what is going on and if I can safely start him on PrEP now vs after rechecking VL. Any thoughts would be appreciated. Thanks!
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Rebecca Kim
Philadelphia PA
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