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  • JAIDS 1998;17:42; JAIDS 1999;21:120; JID 2002;185:428; Lancet 2001;357:1149; AIDS 2001; 15:621; CID 2002;34:391; JID 2005;191:1403; AIDS 2006 ;20:895). In January, 2008, the Swiss Federal Commission for HIV/AIDS issued a statement from P. Vernazza, B. Hirschel and E. Bernasconi that effective ART (defined as <40 c/m for >6 months) eliminates the possibility of transmitting. HIV through sexual contact. Bulletin des Medecins Suisses 2008;89:5). An exception is the concurrent presence of a sexually transmitted disease. Evidence was based on:
    • Four discordant couple studies showing no seroconversions when the positive partner had an undetectable VL (NEJM 2000;342:921; JAIDS 2005;40:96; Melo M. 16th IAS 2006; Abstr. TUPE 0430; JAIDS 2006;43: 324).
    • Lack of functional HIV virions in male and female genital secretions in patients with viral suppression (AIDS 2000;14:117; AIDS 2000;14:415; JID 2006;52: 290; JAIDS 2006;42:584; JAIDS 2007;44:38.
    There is agreement that risk is substantially decreased but disagreement that caution is advised in concluding that there is no risk based on discrepancies sometimes noted between viral loads in plasma vs genital secretions, the small sample sizes of discordant couple studies, and the fact that viral load could become detectable between measurements (STD 2008; 35:55).
  • Therapeutic monitoring: Following initiation of therapy, there is a rapid initial decline in VL over 2-4 weeks (alpha slope), reflecting activity against free plasma HIV virions and HIV in acutely infected CD4 cells. This is followed by a second decline (beta slope) that is longer in duration (months) and more modest in degree (see quantitation, below, under "Frequency and therapeutic monitoring"). The beta slope reflects activity against HIV-infected macrophages and HIV released from other compartments, especially those trapped in follicular dendritic cells of lymph follicles. The maximum antiviral effect is expected by 4 to 6 months. VL is accepted as the most important barometer of therapeutic response, although CD4 count best predicts clinical progression (NEJM 1996; 335:1091; Ann Intern Med 1996;124:984; JID 2002; 185:178). The most important long-term benefit of treatment is achieving a VL <50 c/mL, since some authorities note that clonal sequence analyses show no viral evolution with resistance mutations at that level (JID 2004;189:1452; JID 2004;189:1444).The implication is that there is no viral replication and little likelihood of developing resistance or disease progression. Nevertheless, some blips are associated with lapses in adherence and require counseling on this issue (JID 2007;193:1773).
2007 © John G. Bartlett, M.D. All rights reserved.21

Chapter 2: Laboratory Tests

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