Research on Genotypic HIV drug resistance mutations is published in the Indian Journal of Sexually Transmitted diseases and AIDS. This Journal is Pub Med .This is the research done by us Dr Raj Harjani and Dr Ram Malkani. This shows that there is a primary Genomic drug resistance to HIV where after starting Anti- Retroviral Therapy (ART) we can not achieve complete viral suppression which is expected after 6 months of ART.Hence it is advisable to have Genotypic drug resistance test done in the initial visit and subsequently when treatment fails .
Investigations required in a follow up visit (After 16 weeks to 24 weeks of initiation of ART)
- CD4 Count and CD4%
- Plasma Viral load
- Blood Sugar (Fasting and post prandial)
- Liver Function Test
- Renal function test
- Lipid profile
Investigations Required before starting Anti-Retroviral Therapy (ART)
- HIV Serology
- Plasma Viral Load
- CD4 Absolute count and CD4%
- Genotypic Drug Resistance Test (NRTI, NNRTI, PI, INSTI)
- HLA B5701 for ABC drug (hypersensitivity test)
- HIV tropism for Maraviroc drug
- Serum Cryptococcal Antigen Test (S.CRAG)
- Complete Blood Count (CBC)
- Blood Sugar (Fasting & post prandial)
- Liver Function Test (LFT)
- Renal Function Test (RFT)
- Lipid Profile
- Thyroid Function Test (TFT)
- Vit D3
- Vit B12
- CT Chest and Abdomen
Now AIDS is chronic manageable disease like Diabetes and Hypertension.
Now AIDS is chronic manageable disease like Diabetes and Hypertension. People living with HIV/AIDS are living healthier and thinking of marrying HIV positive or HIV Negative partner (after disclosing their HIV status). Anti-Retroviral Therapy (ART) is now not only used as treatment for HIV infected patients but it is also used as a Treatment for prevention (T4P). T 4 P is Post Exposure Prophylaxis (PEP) and Pre Exposure prophylaxis (PrEP).
nam – aidsmap sys : UNDETECTABLE VIRAL LOAD MEANS NO RISK OF HIV TRANSMISSION Read here …
Sero discordant HIV infected couples …discussion for Pre Exposure Prophylaxis (PrEP)for an uninfected partner, Anti Retroviral Therapy (ART) for infected partner or both
PrEP, ART, or Both? How I Advised a Serodiscordant Couple
John and Sally (not their real names) were married 2 years ago and were recently referred to me when John found out that he was HIV positive. He had a plasma HIV-1 RNA of 91,000 copies/mL and CD4+ cell count of 631 cells/mm3. John has been asymptomatic and Sally has been repeatedly HIV antibody negative. To their knowledge, there have been no high-risk exposures during the past 6 months, although they admit that condom use has not been 100%.
They were referred to me to address their seemingly simple questions regarding Sally’s risks of acquiring HIV from John, how they can minimize the risks, and whether they will ever be able to safely have a child together.
Starting Antiretroviral Therapy
Role of PrEP
I responded that treating John is good for both of them. In addition, I explained that treating Sally with PrEP alone will reduce her acquisition risk but probably to a lesser extent than will treating John (there was a relative reduction of 75% in the overall population in the incidence of HIV infection with tenofovir/emtricitabine in the Partners PrEP trial; 66% in women). In addition, PrEP will not address John’s health risks from untreated HIV and puts Sally at real risk for short-term and long-term toxicity (that could include gastrointestinal effects and fatigue[3-5] and decline in bone mineral density.) Finally, I shared with them that we simply have no data to inform us how much additional protection Sally will derive from receiving PrEP if John’s viral load is suppressed on an antiretroviral regimen. In summary, I told them that my personal view is that as long as John’s viral load is well controlled on treatment, I am not convinced that the theoretical benefits of adding continuous PrEP outweigh the potential risks.
Strategies for Conception
Eric S. Daar, MD, is Chief, Division of HIV Medicine at Harbor-UCLA Medical Center, and Professor of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.
Dr. Daar has disclosed that he has received funds for research support from Abbott, Gilead Sciences, Merck, Pfizer, and ViiV and consulting fees from Bristol-Myers Squibb, Gilead Sciences, Merck, and ViiV.
1. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.
2. Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR Morb Mortal Wkly Rep. 2012;61:586-589
3. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
4. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention. N Engl J Med. 2011;364:1373.
5. Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434.
6. Quinn TC, Wawer JW, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921-929.
7. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for use of antiretroviral drugs in pregnant HIV-1- infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed September 24, 2012.
I take 6 months approximately to treat male HIV-positive man with ART. And once he is investigated and treated for other sexually transmitted diseases, I prescribe TDF + FTC combination pill before and after Intra Uterine Insemination (IUI) to uninfected partner. Results are promising after 3 IUI.
Dr Raj Harjani Mumbai INDIA – 2/3/2013
Cool. Did we get the confimation levels of viral loads before IUI?
Dr Adegboye, NIGERIA – 2/17/2013
We confirm with plasma viral load. once undetectable for at least 2 months, then we consider person fit for sperm wash. Generally all male serodiscordant couples achieve undetectable levels by 4 months.
Dr Raj Harjani Mumbai INDIA – 2/25/2013
In my practice, I have several times come across discordant couples. But the difference with John and Sally’s case is that over 90% of my cases have been HIV advanced with children and irregularly practicing protected sex. We are living in a gender inequality culture where sex practice is male initiative, while woman, regardless her HIV status has no power to oppose her partners choice in term of safer sex practice. In our experience, women are more adherent to treatment than men. At our ARTClinic, discordant couples coming together for review can be estimated as less than 5%, among them those preoccupied about having safely children. We attempt to encourage them to report for routine review visits at ART clinic as a couple for proper IEC (information, education and communication) more especially for discordant couples. The concept of PrEP for uninfected HIV partner is not yet in practice in our ART clinic. We need to start now this important program targeting the concerned couples.
muhemedi – 1/17/2013
I love Joels categorization of the 3 approaches and will quote it widely.
David A. Wohl, MD – 11/11/2012
This question just came up with a male patient of mine who is suppressed and wants to have a child with his HIV-negative wife. They have been scrupulous about using condoms. I described 3 approaches, which I called “safe,” “extremely safe,” and “ridiculously safe.” The “safe” approach is to have unprotected intercourse during times of maximum fertility (determined by home ovulation monitoring), based on the fact that suppressive ART was 96% effective in HPTN 052 (and having an undetectable viral load was 100% effective, something that is less often mentioned). The “extremely safe” approach is to add courses of PrEP for his wife during times of attempted conception. The “ridiculously safe” approach is to use sperm washing. My patient and his wife are inclined to take the middle approach, which seems like a good choice to me. Some have also suggested conceiving by home artificial insemination with a syringe rather than actual intercourse to reduce vaginal trauma, though this seems unnecessary if you’re combining ART and PrEP.
Joel E. Gallant, MD, MPH – 10/29/2012
This is an interesting clinical scenario encountered frequently, and providing concrete answers through data support and clinical trials will definitely help couples to make decisions, and help consulting and treating physicians to provide more precise data for that purpose.
Doctor “T” – 10/24/2012
I agree with Dr T. One question is whether the belt and suspenders approach of ART for him and PrEP for her would offer anything more than ART for John alone? The calculus gets more complex when adding in potential toxicity of tenofovir in Sally (reduced BMD, for instance) and financial cost of PrEP. Short term use during attempts at conception may be more feasible. For the couples I have seen (most often an HIV+ patient of mine and his uninfected partner), the major issue has been access as these folks have no insurance.
David A. Wohl, MD – 10/28/2012
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Which of the following best summarizes your personal experience prescribing oral tenofovir/emtricitabine for PrEP?