TO THE EDITOR:
The availability of new antiretroviral agents has heightened the expectation of therapeutic benefit among patients infected with the human immunodeficiency virus (HIV). Multidrug regimens may reduce plasma HIV RNA levels, which provide valuable prognostic information, until they can no longer be detected [1, 2].
In July 1995, a 37-year-old HIV-positive patient entered an industry-sponsored antiretroviral study. His CD4 cell count increased from 391 cells/mm3 to 613 cells/mm3 at study completion. In July 1996, his primary care provider did an assay for plasma HIV RNA. At this time, the patient was receiving stavudine, lamivudine, and indinavir. The primary care office staff informed the patient by telephone that the result was "71 896." The patient stopped all medication and contacted our research clinic, stating that "the virus is chewing up my CD4 cells," "there is no hope," and "I'll just overdose on narcotics." After reassuring the patient, we suggested that the assay be repeated and told him to resume antiretroviral therapy. The following day, we learned that the date of the report (7/18/96) had inadvertently been read to the patient. He was informed that his plasma contained no detectable HIV RNA.
The past decade has seen fluctuating hopes and expectations among patients with the acquired immunodeficiency syndrome. Enthusiasm about the ability of zidovudine to reduce short-term mortality [3] was replaced by frustration when this benefit was shown to be transient [4, 5]. Enthusiasm re-emerged with more potent antiretroviral agents and with evidence that plasma HIV RNA titers are stronger predictors of long-term prognosis than are CD4 cell counts [1, 2]. However, the emphasis on measuring plasma HIV RNA levels brings new responsibilities. It is important that patients be counseled about both the utility and limitations of this test. Results should ideally be discussed during an office visit. If provided by telephone, this information should be given by persons who understand the importance a patient may attach to the result.
1. Gulick R, Mellors J, Havlir D, Eron J, Gonzalez C, McMahon D, et al. Potent and sustained antiviral activity on indinavir in combination with zidovudine and lamivudine [Abstract]. Third Conference on Retroviruses and Opportunistic Infections. IDSA, NIH, and CDC, 28 January-1 February 1996, Washington, DC.
2. Mellors JW, Rinaldo CR, Gupta P, White RM, Todd JA, Kingsley LA. Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science. 1996; 272:1167-70.
3. Fischl MA, Richman DD, Grieco MH, Gottlieb MS, Volberding PA, Laskin OL, et al. The efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex: a double-blind, placebo-controlled trial. N Engl J Med. 1987; 317:185-91.
4. Hamilton JD, Hartigan PM, Simberkoff MS, Day PL, Diamond GR, Dickinson GM, et al. A controlled trial of early versus late treatment with zidovudine in symptomatic human immunodeficiency virus infection. N Engl J Med. 1992; 326:437-43.
5. Seligmann M, Warrell DA, Aboulker JP, Carbon C, Darbyshire JH, Dormont J, et al. Concorde: MRC/ANRS randomized double-blind controlled trial of immediate and deferred zidovudine in symptom-free HIV infection. Lancet. 1994; 343:871-81.
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