Your point would be? I understand how EM works and I also understand that
the output of EM is rendered as an image just as the ones shown on the two
websites. Which were if you happened to even look all black and white images
so your point about EM's not being in color is a red herring, no one claimed
they produce color images nor were any of the images rendered in color.

No not a stunt, simply what the EM sample showed.

Yes there are that however does not mean that HIV does not exist.

No but HIV is and has been shown to be infectous.

Only in the feeble minds of your ilk.

How then do you explain the images of HIV that I have presented here, or
that the gentic structure of HIV has been sequenced? By the way HIV has been
cultured many different ways compared to Gallo and Montagnier's early work
on the virus, there is no doubt what so ever that it can be cultured, there
are even standerdized tests that depend on culturing HIV.

Can you provide a reference that backs up this claim?

Gary Stein

WITH REGARD TO SURROGATE MARKERS: -

CONCERNS ABOUT HIV/AIDS TESTING AND MEASUREMENT

By David Crowe, Phd

June 2001

HIV-positive people are some of the most poked, prodded, tested and
measured in the world. Yet, surprisingly enough, most of the tests and
measurements are not nearly as accurate as is generally stated.

HIV Testing

HIV testing is generally considered to be extraordinarily accurate. In
fact, it has to be this way, because if people were told that there was a
90% chance that they had a fatal disease and had to take extraordinarily
toxic therapy, many might decide that they were in the 10% of false test
results. Only by claiming that HIV tests are virtually always right can
people be terrorized into taking their medications. Examine these quotes
and consider whether this is really true.

From these quotes you will learn that 20 million HIV tests resulted in
over 20,000 positive tests - but only 112 were true positives! You will
learn that mice and human placentas can be HIV-positive - without exposure
to HIV! You will learn that there is no 'Gold Standard' against which the
tests can be tested. Validation is performed by comparing each test
against the others, like a tiger chasing its tail, with no obvious
beginning or end.

The tests listed below represent all those used to diagnose or monitor HIV
status. If they are not sound, there is no reliable way to diagnose HIV,
and thus no point even discussing how to treat the conditions that it
supposedly causes.

Surrogate Markers

Surrogate markers are measurements that are used not to determine whether
someone has a condition, such as an HIV infection, but to find out how
serious their condition is. CD4 immune cell counts, sometimes in
conjunction with CD8 cell counts, were the first surrogate marker used
instead of a direct measurement of the health of HIV-positive people,
particularly those who do not have any AIDS-defining conditions.
Increasingly, viral load is being used, based on claims that it can
accurately count the number of HIV particles in a sample of blood.
However, surrogate markers have significant limitations. Scientists have
often noted that surrogate markers are never totally reliable and may
result in incorrect treatment decisions, and that changing the value of a
surrogate marker is not guaranteed to improve the health of the patient.

The quotes are categorized as:

   * Antibody Tests (ELISA, Western Blot)
   * Antigen Tests (p24)
   * Co-culture Tests
   * Viral Load (PCR; Polymerase Chain Reaction)
   * Discordance between HIV Tests
   * False Positives
   * Negative HIV Tests with AIDS!
   * HIV Tests in Children
   * Validation: Search for the Gold Standard
   * Surrogate Markers
   * CD4/CD8 Cell Counts
   * Feedback and Comments

Antibody Tests (ELISA, Western Blot)

Antibody tests are the most commonly performed. Usually an ELISA test is
performed, and then repeated if positive. Following that, for positive
ELISAs only, a Western Blot (WB) is performed. ELISA is not a Yes/No test,
it is only a continuum of color change that is interpreted in this way
because of an arbitrary cutoff point. Western Blot has the purported HIV
proteins separated on a strip, with various methods used for
interpretation (varying from country to country, and from organization to
organization). Both types of tests measure antibodies, which in many
diseases are considered a sign of immunity (particularly in the absence of
symptoms). Why are antibody tests considered a sign of fatal disease in
HIV/AIDS? Why are two of the same type of test used to validate each
other?

“Antibodies directed to the env-encoded surface glyco-protein gp160 were
detected in the cervicovaginal secretions of a small proportion of
HIV-seronegative sex workers in Abidjan. In 2.9 to 12.3% of these women,
depending on the test used, the anti-HIV antibodies were present in
vaginal fluids that were free of contaminating semen. Since there is no
established gold standard test, it is unclear which of these two
proportions is the best estimate of the real prevalence rate of
cervicovaginal anti-HIV antibodies in the absence of contaminating semen
in HIV seronegative sex workers...The 25 HIV-1-seronegative sex workers
with anti- HIV antibodies in their semen-free cervicovaginal secretions by
both in-house ELISA and Seradyn Sentinel HIV-1 Urine EIA [ELISA] had no
evidence of HIV-1 RNA in plasma. It is therefore unlikely that these
antibodies are part of a primary HIV infection, although these women were
not followed up...In the present study, increased sexual exposure was not
associated with the presence of HIV-antibodies in cervicovaginal
secretions, as measured by either of the two tests. Similarly, Mazzoli et
al. did not find an association between the duration of unprotected sex
and the presence of HIV-specific antibodies in the urine or cervicovaginal
secretions of HIV-seronegative female partners of HIV-seropositive males
in sero- discordant couples [11].”

Ghys PD et al. Cervicovaginal anti-HIV antibodies in HIV-seronegative
female sex workers in Abidjan, Cote d'Ivoire. AIDS. 2000;14:2603-8.

“The serological diagnosis of HIV infection is usually made on the basis
of the detection of circulating antibodies specific for viral antigens
gp41, gp120 and gp160. Despite using recombinant immunogenic
oligopeptides, which improved the sensitivity and specificity of
immunological tests, a number of both false-positive and false-negative
reactions have been reported. Although the emergence of new viral
serotypes or recent infection could be responsible, at least partly, for
the low sensitivity of serological assays in detecting early antibody
responses, false-positive results could be explained by crossreactions
with unrelated antigens. Spehar and Strand recently demonstrated the
cross- reactivity of anti-gp41 murine monoclonal antibodies with the human
cytoskeletal protein alpha-actinin, and antibodies reacting with both the
immunodominant region of HIV gp41 and alpha-actinin have been found in the
sera of HIV-infected individuals...Only three out of 108 sera with IgG
anti-Tricomonas vaginalis, and one out of 32 with IgM, tested positive for
HIV using both kits.”

Fiori PL, Rappelli P. Do anti-Tricomonas vaginalis antibodies recognize
HIV gp41?. AIDS. 2000;14(13):2057.

“A confirmed positive test [i.e. one or two ELISA tests, followed by a
Western Blot] indicates that a person has been exposed to the virus and
has mounted an immunologic response (serum antibodies). However, this test
does not indicate whether the person currently harbors the virus”

Zhang Z-Q et al. Sexual Transmission and Propagation of SIV and HIV in
Resting and Activated CD4+ T Cells. Science. 1999 Nov
12;286(5443):1353-7.

“[Table shows that of 1,326,030 HIV tests 1,072 had reactive EIA/ELISA
tests that were followed by negative or indeterminate Western Blot. Only
276 were confirmed positive]...Some of the EIA repeat reactive [but] Wb
[Western Blot] negative or ID [indeterminate] donors were tested on
multiple occasions. No donor in...the HIV-1...neg or ID group became Wb
positive...The Wb neg or ID donors outnumbered the confirmed reactives 4
to 1 in HIV-1 testing”

Haley NR et al. Abstract S110: Comparisons of confirmed and unconfirmed
HIV-1 and HTLV-I positive donors to the donor base. Transfusion.
1992;32(suppl):30S.

“In blood donor studies in the developed world, about 20% of sera referred
to confirmatory laboratories give indeterminate western blot results,
almost all of which are on presumed negative specimens.”

Mortimer PP. The fallibility of HIV Western blot. Lancet. 1991 Feb
2;337:286-7.

“100 ELISA-negative donors...were tested by WB [note that normally a
negative ELISA will not result in a Western Blot ‘confirmatory’ test]. 20
were WBi, with p24 being the predominant (70%) and generally the only
band. Among recipients of WBi blood, 36% were WBi in their 6 month
post-transfusion sample, but so were 42% of a control population that had
received only WB-negative blood. When serial samples from recipients with
a WB pattern were tested on two occasions, only 35% of results were
reproducible. No recipients of WBi blood became ELISA positive, true
positive for WB, positive for HIV-1 antigen, or positive for ELISA
reactivity against recombinant p24 or gp41...Thus WBi patterns are
exceedingly common in randomly selected donors and recipients”

Genesca J et al. What do Western Blot indeterminate patterns for Human
Immunodeficiency Virus mean in EIA-negative blood donors?. Lancet. 1989
Oct 28;II:1023-5.

“Natural antibodies capable of neutralizing HTLV-III [HIV] infection of H9
cells were detected in 60% of adult AIDS patients and in 80% of adults
with ARC, but in 0% of normal healthy heterosexual controls. Geometric
mean antibody titers were two-fold higher in ARC patients compared to AIDS
patients and were even higher in 2 antibody positive healthy homosexuals.
This finding suggest that virus neutralizing antibodies may exert some in
vivo protect effect”

Robert-Guroff M, Gallo RC. Method for detecting HTLV-III neutralizing
antibodies in sera. US Patent Office. 1988 Jul 5;4,755,457.

“The strength of ELISA reactivity...was predictive of positivity on
immunoblot [Western Blot] testing. The immunoblot was positive in all 21
specimens with ratios higher than 4.0, in 5 of 7 specimens with ratios of
2.0 to 3.9, and in only 1 of 16 specimens with ratios between 1.0 and 1.9
[this illustrates that the HIV test only became a Black and White test
through an arbitrary cutoff value]”

Hoff R et al. Seroprevalence of Human Immunodeficiency Virus among
Childbearing Women. NEJM. 1988 Mar 3;318(9):525-30.

“Most patients (68 to 89%) from low risk groups (prevalence of 0.1% or
less) who show reactivity on screening tests will have false-positive
results…The predictive value of a positive ELISA varies from 2 to 99%…the
Western blot method lacks standardization, is cumbersome, and is
subjective in interpretation of banding patterns.”

Steckelberg JM, Cockerill F. Serologic testing for human immunodeficiency
virus antibodies. Mayo Clin Proc. 1988;63:373-9.

“approximately 1 percent of all initial screening ELISAs were reactive, 50
percent of repeat ELISAs were reactive, and 30 to 40 percent of first
Western blot assays were reactive and diagnostic.”

Burke DS et al. Measurement of the false positive rate in a screening
program for human immunodeficiency virus infections. NEJM.
1988;319(15):961-4.

“We selected the 20 most strongly [indeterminate or atypical Western Blot]
reactive samples for further evaluation...Atypical WB [Western Blot]
paterns in 19 of 20 of our donors remained substantially the same over
time...our data show that the presence of p24 alone in WB should not be
regarded as a false positive without subsequent testing of the
individual...All study donors had normal immune status...[2] donors were
multiparous females [multiple children], and one other probably had
received a blood transfusion...we observed a large proportion of
individuals who had either lived or worked on dairy farms (6/16) and
frequently drank unpasteurized cows’ milk (7/16)..undefined autoimmune
phenomena [such as multiple pregnancies], bovine exposure, or
corss-reactivity with other human retroviruses could be possible causes
for consistently reactive HIV immunologic assays”

Dock NL et al. Evaluation of atypical human immunodeficiency immunoblot
reactivity in blood donors. Transfusion. 1988;28:412.

“Our data support the use of category I as a positive result [positive WB
if 3 of 4 "key" bands are positive - this was the method used by FDA at
the time]; however, if this were the only criterion that was finally
established as unequivocal positive, more than 50% of patients with AIDS
would be put into a "probable" positive or indeterminate category. Our
data support the inclusion of categories I, IIa and IIb as unequivocal
positives [basically you need 2 of 4 key bands]. Applying these criteria
would increase the percent positive for patients with AIDS to 79% without
diminishing specificity”

Lundberg GD. Serological diagnosis of Human Immunodeficiency Virus
infection by Western Blot testing. JAMA. 1988;260:674-9.

“Reactivity with [HIV proteins] p24 and/or gp41 has been suggested as a
minimum requirement for HIV seropositivity by WB [Western Blot]. While
testing ELISA positive serum from Swedish blood donors we detected 3 sera
with false-positive WB reactions to p24 and p55...The 3...had no risk
factors for HIV infection”

Biberfeld G et al. Blood donor sera with false-positive western blot
reactions to human immunodeficiency virus. Lancet. 1986 Aug 2;2:289-90.

“The sera [from 6720 blood donors] were examined by various enzyme-linked
immunoassay (ELISA) screening tests and, usually, by one of three types of
confirmatory assay. 45 samples (0.21%) were confirmed as positive. Only 2
were positive in all three confirmatory tests.”

Hunsmann G. HTLV-III antibody Positive Blood Donors. Lancet. 1985 May
25;1:1223.

“When the ELISA is used to screen populations in whom the prevalence of
HTLV-III infections is low, the proportion of positive results that are
falsely positive will be high”

Provisional Public Health Service Inter-Agency Recommendations for
Screening Donated Blood and Plasma for Antibody to the Virus Causing
Acquired Immunodeficiency Syndrome. MMWR. 1985 Jan 11;34(1):1-5.

“Of 96 patients with AIDS or AIDS-related complex and healthy individuals
at risk for AIDS, 4 had no detectable antibodies to viral proteins, though
[HIV] was isolated from their lymphocytes. 3 of these subjects were
symptom-free and 1 had lymphadenopathy. All 4 were sexual partners of
patients with AIDS or AIDS-related complex...none of the patients studied
here had evidence of impaired production of antibody other viruses”

Salahuddin SZ et al. HTLV-III in symptom free seronegative persons.
Lancet. 1984 Dec 22/29;2:1418-20.

“The results provide evidence for the involvement of LAV [HIV] in
AIDS...Specific antibodies against [HIV] have been detected in
approximately 70 percent of patients with persistent lymphadenopathy and
40 percent of AIDS patients studied.”

Klatzmann D et al. Selective tropism of lymphadenopathy associated virus
(LAV) for helper-inducer T lymphocytes. Science. 1984 Jul 6;225:59-63.

“Antibody to LAV [HIV] p25 [p24] was found in the serum of 51 of 125 AIDS
patients, 81 of 113 patients with lymphadenopathy syndrome, 0 of 70
workers at the Centers for Disease Control (some of whom had handled
specimens from AIDS patients), and 0 of 189 random blood donors.”

Kalyanaraman VS et al. Antibodies to the core protein of
lymphadenopathy-associated virus (LAV) in patients with AIDS. Science.
1984 Jul 20;225(4659):321-3.

“A positive [antibody] test for most individuals in populations at greater
risk of acquring AIDS will probably mean that the individual has been
infected at some time with [HIV]. Whether the person is currently infected
or immune is not known, based on the serologic [antibody] test alone -
[HIV] has been isolated in both the presence and absence of antibody ”

[e-version incomplete] et al. Antibodies to a retrovirus etiologically
associated with acquired immunodeficiency syndrome (AIDS) in populations
with increased incidences of the syndrome. MMWR. 1984 Jul
13;33(37):377-9.

Antigen Tests (p24)

Antigen tests are the opposite of antibody tests. An antibody is a protein
produced by an immune system in response to a foreign protein (the
antigen), such as a virus coat. Antigen tests (usually with the p24/p25
protein) have not been spectacularly successful, because may people who
are antibody positive do not have HIV antigen. One would think that this
would mean that these people have only been exposed to HIV (hence the
antibodies) but not infected (hence no antigens). Yet, in the topsy-turvy
world of AIDS, the opposite interpretation is taken.

“p24 antigen was detected in 6 patients of group P [positive] and 2
patients of group N [HIV-negative]. ”

Urano H et al. HIV isolation may not correlate with clinical state or
immunological function of respective HIV infected patients. Int Conf AIDS.
1994 Aug;10(2):255.

“At the time of delivery, HIV-1 p24 antigen was detected in serum from 16
of 108 [HIV+] women (15%)”

Blanche S. Relation Of The Course Of HIV Infection In Children To The
Severity Of The Disease In Their Mothers At Delivery. NEJM. 1994 Feb
3;330(5):308-12.

“Of 61 infected children tested 46 (75%) had at least one positive test
for antigen”

Kind C et al. Epidemiology of vertically transmitted HIV-1 infection in
Switzerland: results of a nationwide prospective study. Eur J Pediatr.
1992;151:442-8.

“Alloimmune mice...were shown to make antibodies against gp120 and p24 of
human immunodeficiency virus (HIV), and mice of [two] autoimmune
strains...made antibodies against gp120. This is surprising because the
mice were not exposed to HIV. [i.e. HIV proteins are found in uninfected
mice!!]”

Kion TA, Hoffmann GW. Anti-HIV and anti-anti-MHC antibodies in alloimmune
and autoimmune mice. Science. 1991 Sep 6;253:1138-40.

“Baseline serum p24 antigen levels were measured in 71 patients. At entry,
37 (52%) were positive for the antigen...and 34 (48%) were negative [yet
all were positive for HIV antibodies]”

McKinney RE et al. A multicenter trial of oral zidovudine in children with
advanced human immunodeficiency virus disease. NEJM. 1991 Apr
11;324(15):1018-25.

“Cryostat sections of human normal term placentae were …examined for HIV
protein antigens gp120, p17, p24, and gp41. No evidence for gp41 was
found. Antigens gp120 and p17 were identified in normal chorionic villi in
vimentin-positive fibroblast-like cells and in endothelium, respectively.
Antigen p24 was localized to HLA-DR positive cells that morphologically
resembled macrophages in areas of villitis. [i.e. HIV proteins are found
in uninfected human placentas!!]”

Faulk WP, Labarrere CA. HIV proteins in normal human placentae. American
Journal of Reproductive Immunology. 1991;25:99-104.

“HIV-1 p24 is the HIV-1 protein most prone to "false-positive" reactions”

Ng V. Serological diagnosis with recombinant peptides/proteins. Clin Chem.
1991;37(10):1667-8.

“there were 16 sera from 30 viraemic patients which did not have
detectable p24 antigen”

Semple M et al. Direct measurement of viraemia in patients infected with
HIV-1 and its relationship to disease progression and zidovudine therapy.
J Med Virol. 1991;35:38-45.

“there were 16 sera from 30 viraemic patients which did not have
detectable p24 antigen (<5 pg/ml, Fig. 2). As a consequence, p24 antigen
concentration and HIV-1 RNA did not correlate well.”

Semple M et al. Direct measurement of viraemia in patients infected with
HIV-1 and its relationship to disease progression and zidovudine therapy.
J Med Virol. 1991;35:38-45.

“205 subjects (of 406 tested (50%)) had detectable serum levels of HIV
antigen before treatment [i.e. 50% were negative for HIV antigen, although
positive for HIV antibodies]”

Fischl MA et al. A randomized controlled trial of a reduced daily dose of
Zidovudine in patients with the Acquired Immunodeficiency Syndrome. NEJM.
1990;323(15):1009-14.

“In only 45 percent of persons from whom we isolated plasma-associated HIV
[by co-culture techniques] was p24 antigen detected in plasma or serum”

Coombs RW et al. Plasma viremia in human immunodeficiency virus infection.
NEJM. 1989 Dec 14;321(24):1626-31.

“In only 45 percent of persons from whom we isolated plasma-associated HIV
was p24 antigen detected in plasma or serum”

Coombs RW et al. Plasma viremia in human immunodeficiency virus infection.
NEJM. 1989 Dec 14;321(24):1626-31.

“no infants, including those who later had AIDS, were positive for serum
antigen [p24] during the neonatal period”

Rogers MF et al. Use of the polymerase chain reaction for early detection
of the proviral sequences of human immunodeficiency virus in infants born
to seropositive mothers. NEJM. 1989 Jun 22;320(25):1649-54.

“Whether the production of HIV antigen [p24 or p25] accurately reflects
complete viral replication with the production of infectious virions is
still to be investigated”

Lange JMA et al. Persistent HIV antigenaemia and decline of HIV core
antibodies associated with transition to AIDS. BMJ. 1986;293:1459-62.

“antibodies to the structural proteins of HTLV, notably p24 and p19 are
not detectable in most AIDS patients”

SchŸpbach J et al. Serological Analysis of a Subgroup of Human
T-Lymphotropic Retroviruses (HTLV-III) Associated with AIDS. Science. 1984
May 4;224:503-505.

Co-culture Tests

Co-culture is often claimed to result in 'isolation' of HIV. However,
co-culture is a very complicated procedure, with lots of opportunities for
misinterpretation of data, and with very vague outcomes. Co-cultures are a
combination of an immortal line of cancerous cells, a sample of cells or
fluids from a potentially HIV-infected person and stimulating chemicals.
Detection of one of a number of non-specific phenomena (e.g. reverse
transcriptase activity, p24 antigen, production of particles about the
size and shape of a retrovirus) in this witches brew is assumed to be
proof of the presence of HIV in the original sample. However, none of
these phenomena are specific to a retrovirus, let alone HIV.

“the expression of HERVs [Human Endogenous Retroviruses] has been linked
with disruption of immune function, particularly associated with
autoimmune disease. Reports of retrovirus-like particles in Sjogren’s
syndrome and sequencesw in Graves disease and multiple sclerosis suggest
that their expression may have considerable impact on the immune
system...We detected a 6 kb mRNA and lower levels of a 4.5 kb RNA...in
PHA-stimulated T cells...the transcripts are absent or undetectable in
unstimulated T cells [which, by extension, could mean that HIV is an
endogenous (built-in) retrovirus that is inactive until stimulated by PHA
using co-culture techniques]”

Kelleher CA et al. Expression of novel-transposon-containing mRNAs in
human T cells. J Gen Virol. 1996;77:1101-10.

“Overall, plasma viremia [as measured by culture] developed during
follow-up in 17 of 27 patients (63 percent) who initially did not have
viremia, and was sustained in 35 (88 percent) of the 40 patients who
initially had viremia”

Coombs RW et al. Plasma viremia in human immunodeficiency virus infection.
NEJM. 1989 Dec 14;321(24):1626-31.

“#879 claims that this shows that ÒHIV culture-positive rate [is] 20% in
high-risk, antibody-negative peopleÓ”

Imagawa DT et al. Human immunodeficiency virus type I infection in
homosexual men who remain seronegative for prolonged periods. NEJM. 1989
Jun 1;320(22):1458-62.

“The main difference in the [retroviral and retrotransposon life] cycles
is the presence of infectious, extracellular, membrane-enveloped particles
in the retroviruses [i.e. the presence of reverse transcription cannot be
taken to indicate the presence of any retrovirus, let alone a specific
retrovirus]”

Boeke JD, Corces VG. Transcription and reverse transcription of
retrotransposons. Ann Rev Microbiol. 1989;43:403-34.

“The protein fraction [of HIV] is obtained by disruption of sucrose
gradient purified HTLV-III [HIV] [without any proof that the material
obtained represents a retrovirus, let alone HIV]”

Saxinger WC, Gallo RC. Competitive ELISA for the detection of HTLV-III
antibodies. US Patent Office. 1987 Apr 28;4,661,445.

“Continuous production of HTLV-III is obtained after repeated exposure of
parental HT cells to concentrated [not purified] culture fluids containing
HTLV-III harvested from short term cultured T-cells (grown with TCGF
[T-Cell Growth Factor]) which originated from patients with pre-AIDS or
AIDS. The concentrated fluids were first shown to contain
particle-associated reverse transcriptase (RT) [i.e. no direct evidence of
the presence of a retrovirus]...Samples exhibiting more than one of the
following were considered positive [for an HTLV-family virus]: repeated
detection of a Mg++ dependent reverse transcriptase activity in
supernatant fluids [but reverse transcription occurs in cells even without
retroviruses present]; virus observed by electron microscopy [but merely
looking at particles cannot prove that they are retrovirus particles];
intracellular expression of virus-related antigens detected with
antibodies from sero-positive donors or with hyperimmune serum [but,
without purification of HIV, it is not possible to say with certainty what
virus-related antigens are, and even if it was, antibody cross-reactions
are still possible]; or transmission of particles, detected by reverse
transcriptase assays or by electron microscopic observation, to fresh
human cord blood, bone marrow, or peripheral blood T-lymphocytes [but the
ability to stimulate a cellculture to produce particles is not proof that
an infectious agent is present, and certainly not that it is a specific
retrovirus]. All isolates not classified as either HTLV-I or HTLV-II by
immunological or nucleic acide analysis were classified as HTLV-III.”

Gallo RC, Popovic M. Method of continuous production of retroviruses
(HTLV-III) from patients with AIDS and pre-AIDS using permissive cells. US
Patent Office. 1987 Mar 24;4,652,599.

“The study population consisted of...patients with AIDS and patients with
AIDS-related complex...The criteria for eligibility also included...an
absolute number of [CD4 cells] less than 500 per cubic millimeter...,
serum positive for antibody to HIV...HIV was isolated [by co-culture] at
entry in 57 percent of the AZT group and 58 percent of the placebo group
[i.e. almost half of patients with AIDS and pre-AIDS were negative by HIV
by culturing techniques]”

Fischl MA et al. The Efficacy of Azidothymidine (AZT) in the Treatment of
Patients with AIDS and AIDS-Related Complex. NEJM. 1987;317:185-191.

“In an early set of experiments, HTLV-III [HIV] was cultured from 48
subjects, including 18 or 21 patients with ARC [AIDS-related Complex, also
known as pre-AIDS], 3 of 4 clinically normal mothers of children with
AIDS, and [only] 26 of 72 adults and children with AIDS...Of interest is
the finding, that while antibody to HTLV-III was more often associated
with advanced disease, HTLV-III itself was more frequently culture in ARC
or newly diagnosed AIDS patients”

Layon J, Warzynski M, Idris A. Acquired immunodeficiency syndrome in the
United States: a selective review. Critical Care Medicine.
1986;14(9):819-27.

“In the last few years, the view that reverse transcription is solely a
retroviral mechanism has been disproven [even though this assumption is
the basis of much co-culture evidence]”

Baltimore D. Retroviruses and retrotransposons: the role of reverse
transcription in shaping the eukaryotic genome. Cell. 1985
Mar;40(3):481-2.

“Evidence for the presence of HTLV-III included: (i) viral reverse
transcriptase (RT) activity in supernatant fluids; (ii) transmission of
virus by coculturing T cells…; (iii) observation of virus by electron
microscopy; and (iv) the expression of viral antigens…using serum from a
patient positive for antibodies to HTLV-III…or antisera prepared against
purified, whole disrupted HTLV-III”

Gallo RC et al. Frequent Detection and Isolation of Cytopathic
Retroviruses (HTLV-III) from Patients with AIDS and at Risk for AIDS.
Science. 1984 May 4;224:500-3.

“…a growing constellation of eukaryotic genetic elements Ð various
pseudogenes and repetitive sequences Ð appear to depend upon reverse
transcriptases of unknown provenance for their existence or amplification
[yet, in an HIV-coculture, the presence of reverse transcription is
considered unambiguous evidence for the existence of HIV]”

Varmus HE. A growing role for reverse transcription. Nature. 1982 Sep
16;299(5880):204-5.

Viral Load (PCR; Polymerase Chain Reaction)

Viral load tests are often claimed to detect the genetic material of HIV,
either the DNA embedded in infected cells or the RNA in viral particles
circulating in the body. Yet these tests search for only a small fraction
of the HIV genome, and HIV has never been properly isolated to allow the
genome to be unambiguosly determined. Furthermore, the viral load test
cannot distinguish between infectious and defective virus, and in some
studies only 1 out of 60,000 viral particles was estimated to be
infectious (see section on discordance).

“That a clinical benefit may not have been achieved with multi-drug rescue
therapy calls into question the current wisdom of deeming an undetectable
viral load the goal of therrapy in the heavily pre-treated population.
Even if it can be accepted that an undetectable viral load is an
appropriate surrogate marker for clinically relevant outcomes in
treatment-inexperienced patients who are initiating combination therapy,
it cannot necessarily be accepted without proof that it is a useful
surrogate in heavily pre-treated patients...Therefore, until controlled
trials are able to prove the utility of an undetectable viral load as a
surrogate marker for clinically relevant outcomes in heavily pre-treated
patients, we bleieve that clinicians should show caution before striving
for complete viral suppression at any cost”

Deeks SG, Martin JN. Editorial Comment: Reassessing the goal of
antiretroviral therapy in the heavily pre-treated HIV-infected patient.
AIDS. 2001;15(1):117-9.

“Because of the RNA assay's 1.9% to 3.0% false-positive rate, results must
be carefully interpreted and compared to HIV-1 viral load levels seen
during proven HIV-1 seroconversion. We report the case of a sexually
active woman with symptoms suggestive of ARS who had a false-positive
HIV-1 RNA assay result.”

More D et al. Utility of an HIV-1 RNA assay in the diagnosis of acute
retroviral syndrome. S Med J. 2000 Oct;93(10):1004-6.

“Negative results (<50 copies/mL), were obtained in 30/32 (94%) [bDNA 3.0]
assays [meaning that false-positive results were obtained in 2/32 or 6% of
cases]”

Erice A et al. Performance characteristics of the bDNA 3.0 assy for
quantitation of HIV-1 RNA in plasma [abstract]. 7th Conf. Retroviruses and
Opp Infections. 2000 Jan 30-Feb 2.

“In contrast to previous reports...the viral load in the majority of the
[long-term survivors] tested was detectable and, in some [long-term
survivors], quite high...and variable over time.”

Betts MR et al. AIDS Res Hum Retro. 1999 Oct;15:1219-28.

“The results obtained for patients with a broad range of plasma viral
loads before and after antiretroviral therapy reveal a constant mean viral
(v)RNA copy number (3.6 log10 copies) per infected cell, regardless of
plasma virus load or treatment status.”

Hockett RD et al. Constant Mean Viral Copy Number per Infected Cell in
Tissues Regardless of High, Low, or Undetectable Plasma HIV RNA. Journal
of Experimental Medicine. 1999 May 17;189(10):1545-54.

“Plasma viral load tests for HIV-1 were neither developed nor evaluated
for the diagnosis of HIV-1 infection; therefore their diagnostic
specificity is not well delineated when applied to persons who are
negative for HIV antibody. We report two cases of false-positive results
obtained by using branched-chain DNA assay...and one case...by using HIV
reverse transcriptase polymerase chain reaction (RT-PCR)...These three
cases illustrate the potential problems of using HIV-1 plasma viral load
tests for diagnosis of HIV infection...Only patients who have a high
pre-test probability of a positive result should be evaluated for primary
infection by using plasma viral load testing [i.e. preconceptions about
risk groups such as gay men makes a positive test more likely]...Their
performance in patients who are not infected with HIV is unknown”

Rich JD et al. Misdiagnosis of HIV Infection by HIV-1 Plasma Viral Load
Testing: A Case Series. Ann Int Med. 1999 Jan 5;130:37-9.

“We observed that clade A strains [of HIV] were not detected by RT-PCR
[Reverse Transcriptase-Polymerase Chain Reaction] and that clade G-strains
were not detected by NASBA [Nucleic Acid Sequence-Based Amplification].
However, the copy number detected by RT-PCR in one clade E (CM235) and in
one clade F (163.3070) was much lower than the copy number detected by
bDNA [branched DNA] and NASBA...for clades B and D (UG270), the HIV-1 RNA
levels measured by bDNA were lower than those obtained by RT-PCR and
NASBA”

Coste J et al. Effect of HIV-1 genetic diversity on HIV-1 RNA
quantification in plasma: comparative evaluation of three commercial
assays. JAIDS. 1997;15:174.

“The AMPLICOR HIV-1 MONITOR Test is an in vitro nucleic acid amplification
test for the quantitation of Human Immunodeficiency Virus Type 1 (HIV-1)
RNA in human plasma...[It] is not intended to be used as a screening test
for HIV or as a diagnostic test to confirm the presence of HIV
infection...Quantitative [co-]culture has limited utility for monitoring
virus levels in infected individuals since only a small fraction of virus
particles is infectious in vitro. Infectious virus is often undetectable
in asymptomatic individuals...The clinical specificity of the...test was
determined by analysis of 495 anti-HIV-1 negative blood donors. None of
these specimens was reactive...Assuming a zero prevalence of HIV-1
infection in the seronegative blood donors, the specificity of the test
was 100%”

Amplicor HIV-1 Monitor Test. Roche. 1996.

“the high level of plasma virus observed by Piatak et al, was about 99.9
per cent non-culturable, suggesting that it was either neutralized or
defective. Therefore, rather than supporting a cytopathic model, this
observation actually may help explain the relatively slow dissemination of
the infected cell burden and thus the relative ineffectiveness of therapy
with nucleoside analogues which target this process.”

Sheppard HW, Ascher MS, Krowka JF. Viral burden and HIV disease. Nature.
1993 Jul 22;364(6435):291-2.

“Circulating levels of plasma virus determined by QC-PCR also correlated
with, but exceeded by an average of nearly 60,000-fold..., titers
[amounts] of infectious HIV-1 determined by quantitative endpoint dilution
culture of identical portions of plasma.”

Piatak M Jr et al. High levels of HIV-1 in plasma during all stages of
infection determined by competitive PCR. Science. 1993 Mar
19;259:1749-54.

“Our study of PBMC [Peripheral Blood Mononuclear Cells] from 56
HIV-1-seropositive patients, using in situ hybridization alone, also [as
did other studies] revealed only 1 in 5000 to 1 in 100,000 cells positive
for HIV-1-specific nucleic acids [DNA]...Our finding with the use of in
situ PCR that large numbers [if you consider 0.1% to 13.5% of cells a
‘large number’] of PBMC from HIV-1-seropositive patients contain the
provirus suggests that direct cytopathic [cell-killing] effects of the
virus may be an important but not necessarily the sole cause of depletion
of CD4-positive lymphocytes. Our data also argue strongly against the
theory that HIV-1 is not the primary etiologic [causative] agent of AIDS
[huh?]...we were able to...show a relation between viral load and the
stage of HIV-1 clinical infection. Patients in Stage II [HIV+, but no
symptoms] had a significantly lower percentage of HIV-1-positive PBMC than
those in Stage III and Stages IV-A to IV-C [but the authors neglect to
mention that this is only true of the average value, there was
considerable overlap between individual values. More importantly, they
also do not mention that the average value at Stage III (lymph gland
enlargement) was higher than at Stage IV-A to C (AIDS) and much higher
than at Stage IV-D (Kaposi’s Sarcoma)]. Patients in Stage IV-D (who had
Kaposi’s sarcoma only) had relatively low numbers of HIV-1-infected
cells.”

Bagasra O et al. Detection of human immunodeficiency virus type 1 provirus
in mononuclear cells by in situ polymerase chain reaction. NEJM.
1992;326(21):1385-91.

“This proficiency study of PCR detection of HIV-1 DNA in serum identified
a disturbingly high rate of nonspecific positivity with a widely employed
gag primer pair system. In fact, the overall rate of positivity was not
significantly different for serum specimens from serpositive patients and
seronegative control donors (26% versus 18%) [some would say that HIV DNA
should not be found in serum, which means that these are all false
positive reactions]”

Busch MP et al. Poor sensitivity, specificity, and reproducibility of
detection of HIV-1 DNA in serum by polymerase chain reaction (PCR).
Journal of Acquired Immune Deficiency Syndrome . 1992;5(9):872-879.

“We found that in infected but asymptomatic patients with HIV-1, [an
average of] 1 in 50,000 PBMC harbored the virus. When such a patient’s
condition progressed to AIDS-related complex or AIDS, the viral titer
increased significantly, to approximately 1 in 400 PBMC...It is unclear
from this study, however, what percentage of the infected cells carry
HIV-1 latently and what percentage of the cells express the virus
actively. If 1 in 10,000 PBMC...express viral messenger RNA...then 99.6%
of the infected monuclear cells harbor the virus latently and the
remaining 0.4 % express it actively [i.e. 1 in 100,000 cells have active
virus!]...this information on the quantitation of HIV-1 [Òhigh levels of
HIV-1 viremiaÓ] should reduce residual doubts about whether HIV-1 is the
true etiologic agent of AIDS”

Ho DD et al. Quantitation of Human Immunodeficiency Virus type 1 in the
blood of infected persons. NEJM. 1989;321(24):1621-5.

“we analyzed samples from individuals konwn to be at especially high risk
of HIV infection-seronegative sexual partners of seropositive
individuals...Of 16 seronegative partners tested, 5 were unequivocally
positive for HIV DNA. The clinical records of these 5 subjects confirmed
that they were seronegative by enzyme-linked immunsorbent assay and
western blot and negative for the p24 antigen at the time the blood
samples were taken for the DNA assay...the same 5 samples were found to be
positive with a second HIV-specific oligonucleotide...The serological
[antibody] status was confirmed in each case and each of the 5 individuals
was negative for anti-HIV antibodies and p24 antigen 2 and 3 months after
the initial detection of HIV DNA”

Loche M, Mach B. Identification of HIV-infected seronegative individuals
by a direct diagnostic based on hybridization to amplified viral DNA.
Lancet. 1988;ii:418-21.

“A reanalysis is presented of 43 cases of apparent transient viremina [one
or more positive culture or PCR assays for HIV-1 and the subsequent
inability to detect HIV-1 in the speciments on multiple occasions or
seroreversion, or both]. 41 cases occurred among 1561 infants in five
studies of mother-to-infant HIV-1 transmission...Our negative studies of
43 cases of suspected transient infection indicate that the
phenomenon...remains to be proven and that most cases suggestive of
transient HIV-1 infection are cases of mislabeling of specimens or their
contamination in the laboratory”

Frenkel LM et al. Genetic Evaluation of Suspected Cases of Transient HIV-1
Infection of Infants. Science. 15 May 1998;280:1073-1077.

“A reanalysis is presented of 43 cases of apparent transient viremina [one
or more positive culture or PCR assays for HIV-1 and the subsequent
inability to detect HIV-1 in the speciments on multiple occasions or
seroreversion, or both]. 41 cases occurred among 1561 infants in five
studies of mother-to-infant HIV-1 transmission...Our negative studies of
43 cases of suspected transient infection indicate that the
phenomenon...remains to be proven and that most cases suggestive of
transient HIV-1 infection are cases of mislabeling of specimens or their
contamination in the laboratory”

Frenkel LM et al. Genetic Evaluation of Suspected Cases of Transient HIV-1
Infection of Infants. Science. 15 May 1998;280:1073-1077.

Discordance between HIV Tests

There are many examples of inconsistency between different HIV tests. This
may mean that all but one of the tests are giving false results. But,
which one? And, how do we know that any of the tests are giving valid
results (see section on validation)?

“[conditions associated with false positive ELISA are] autoimmune disease,
renal failure, cystic fibrosis, multiple pregnancies, blood transfusions,
liver diseases, parenteral substance abuse, hemodialysis, or vaccinations
for hepatitis B, rabies, or influenza...Causes of indeterminate WB
[Western Blot] results include...nonspecific antibody reactions (eg, due
to lymphoma, multiple sclerosis, injection drug use, liver disease, or
autoimmune disorders). Also, there appear to be healthy individuals with
antibodies that cross-react with specific HIV-1 peptides or recombinant
antigens...The Association of Public Health Laboratories now recommends
that patients who have minimal positive results on WB, eg, p24 and gp160
only, or gp41 and gp160 only, be told that these patterns have been seen
in persons who are not infected with HIV and that follow-up testing is
required to determine actual infective status. The clinician must judge
the test results within the context of other epidemiological and clinical
information [i.e. gay men and IV drug users are likely to be defined as
positive based on this prejudice in the presence of ambiguous test
results]. In the appropriate clinical setting, positive ELISA and WB test
results in patients with a normal CD4 + count and CD4/ CD8 ratio and
undetectable HIV-1 RNA should be questioned, repeated, or confirmed with
supplemented testing. A false-positive serological test result may be
supported by normal CD4 + count and CD4/CD8 ratio and undetectable HIV-1
RNA, but is ultimately established by subsequent serological testing and,
especially, close follow-up. [i.e. there is no test that can be absolutely
relied on]”

Mylonakis E et al. Report of a False-Positive HIV Test Result and the
Potential Use of Additional Tests in Establishing HIV Serostatus. Arch
Intern Med. 2000 Aug 14/28;160:2386-8.

“LTNP [long-term non-progressor (to AIDS)] status was defined as
asymptomatic HIV-1 infection for at least 8 years with stable CD4+ cell
counts and no antiretroviral therapy...A wide range of plasma viral loads
was observed among the LTNPs with HIV-1 RNA levels ranging from < 20 up to
860,000 RNA copies/ml plasma and a similar range was observed for the
controls [Median: 40,000; Range: 2,200 up to 1,860,000] (Table I)...Among
the 47 LTNPs with plasma viral load higher than 800 copies/ml, 30 had a
viral load higher than 10,000 copies/ml and 3 had a viral load higher than
500,000 copies/ml despite fulfilling the inclusion criteria.”

Candotti D et al. Status of long-term asymptomatic HIV-1 infection
correlates with viral load but not with virus replication properties and
cell tropism. J Med Virol. 1999 July;58(3):256-63.

“a peripheral blood sample was positive for HIV-1 by culture and a second
sample from a separate blood draw was positive by either culture or HIV-1
DNA polymerase chain reaction (PCR) testing. Uninfected infants had at
least two peripheral blood samples that were negative for HIV-1 by both
culture and DNA PCR, with 1 or the 2 samples obtained at no earlier than
14 weeks of age. We did HIV-1 antibody testing on the infants at 12 and 18
months of age to confirm their HIV-1 infection status. We defined infants
with a confirmed infection as having an early infection if a peripheral
blood sample drawn within 24h of birth was positive for HIV-1 by culture
or DNA PCR testing. Likewise, infected infants were defined as having a
late infection if a peripheral blood sample drawn within 24h of birth was
negative by culture or DNA PCR testing. Infected infants who did not have
a blood sample obtained within the first 24h after birth were not further
classified. Results from cord blood samples were not used for the
determination of infection status nor for the timing of infection...Twelve
infants were positive by both tests at [the study visit at which each of
the 19 infected infants first had a positive virologic test], 5 were
positive only by PBMC culture, and 2 were positive only by DNA PCR. Nine
infected infants had plasma cultures done at the first positive visit, and
5 (56%) were positive. Likewise, 11 had quantitative RNA PCR testing done,
and all were positive.”

Van Dyke RB et al. The Ariel Project: A Prospective Cohort Study of
Maternal-Child Transmission of Human Immunodeficiency Virus Type 1 in the
Era of Maternal Antiretroviral Therapy. JID. 1999 Feb;179(2):319-28.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
1...had 3 negative HIV EIA [ELISA antibody test] results in the 2 years
before admission, and 5 other document negative EIA tests in the 8 years
before that. On one occasion, 9 years before admission, one reactive HIV
EIA test result was obtained, but the confirmatory Western blot result was
negative...After the diagnosis of HIV infection was confirmed by HIV RNA
PCR, the patient was prescribed zidovudine and lamivudine. Two weeks after
initiation of therapy, serum from the patient was strongly reactive with
all HIV EIA”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
2...HIV EIA result was negative during admission, but HIV infection was
identified by HIV p24 antigen testing and DNA PCR...His wife was tested
for HIV infection by HIV EIA and DNA PCR; the results of both tests were
negative ”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
3...HIV-1 EIA and an HIV-1/2 combination test administered 1 month [after
hospital admission] were negative...HIV-1 p24 antigen tests were
positive...The diagnosis of HIV infection was confirmed by HIV-1 DNA PCR.
During the following 27 months, the patient had eight negative HIV EIA
results; 3 HIV-1 DNA PCR tests and 3 HIV-1 RT PCR tests were positive”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
4...first HIV EIA, performed at the time of diagnosis of oral thrush 4
months [after persistent high fever], was negative...[8 months later,
after worsening health problems] an HIV EIA result was negative...[but]
specimens were positive by DNA PCR and p24 antigen tests...In the 11
months following the positive PCR and antigen tests at CDC, the patient
had 3 negative HIV EIA results”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
5...results of two HIV EIA performed during the initial evaluation [for
acute respiratory distress] were negative, although two quantitative
RT-PCR tests were positive...Viral [co-]culture was positive; however, a
later blood sample...was negative by HIV EIA and positive by p24 antigen
EIA...The patient had 4 children...All were tested by HIV EIA, p24 antigen
EIA, and RNA PCR with negative results”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“This report describes the field and laboratory investigation of eight
patients who had clinical evidence of HIV infection, but repeatedly
negative HIV-1 antibody screening results in the course of their clinical
care. In all patients, HIV infection was proven [sic] by other diagnostic
methods [PCR/viral load, p24 antigen and co-culture techniques]...Patient
6...became acutely ill after vaccination for measles, mumps and
rubella...[she had a] negative HIV EIA on 2 occasions, a positive HIV-1
p24 antigen result, and a positive HIV-1 DNA PCR result. Prior HIV EIA
results were negative 2 years, 1 year and 2 weeks before
hospitalization...Of her 17 lifetime sexual partners, four were tested at
CDC by HIV EIA and HIV-1 DNA PCR; all test results were negative”

Sullivan PS, Schable C. Persistently negative HIV-1 antibody enzyme
immunoassay screening results for patients with HIV-1 infection and AIDS:
serologic, clinical, and virologic results. AIDS. 1999 Jan 14;13(1):89-96,
www.aidsonline.org.

“there is approximately 15% probability that an HIV-negative sample will
evidence nonspecific reactions to p24 on WB [Western Blot]...samples with
strong reactivity to gag antigens...including p17, p24, p32, p46...and
p55...can be misinterpreted as p17, p24, p31, gp41 and p55 bands, and this
results in an overall positive interpretation...The 4 donors we studied
all lacked HIV risk factors and were proven by HIV PCR and, in two cases,
culture and p24 antigen analyses not to be infected”

Sayre KR et al. False positive HIV-1 Western Blot tests in noninfected
blood donors. Transfusion. 1996;36:45-52.

“HIV was isolated from 32 patients (54%) of 59 [HIV+] patients examined.
In the group with positive blood culture (group P), CD4+ cell count and
CD4/8 were significantly lower than those in the group with negative blood
culture (group N). p24 antigen was detected in 6 patients of group P and 2
patients of group N. There was no difference in beta 2-m and cytokine
levels between the two groups. HIV isolation had no influence on the
subsequent changes in the clinical state and immunological data.”

Urano H et al. HIV isolation may not correlate with clinical state or
immunological function of respective HIV infected patients. Int Conf AIDS.
1994 Aug;10(2):255.

“Culturable virus in plasma was reduced to undetectable levels coincident
with seroconversion in five of six patients, and was substantially reduced
in the sixth. Circulating p24 antigen also decreased with seroconversion,
even by use of immune complex dissociation tests. However, despite
decreases in total plasma virus levels by QC-PCR of up to 236-fold that
closly paralleled declines in culturable virus, plasma virion-associated
RNA remained readily detectable throughout the full follow-up in all six
patients.”

Piatak M et al. Viral dynamics in primary HIV-1 infection. Lancet. 1993
Apr 24;341:1099.

“Circulating levels of plasma virus determined by QC-PCR also correlated
with, but exceeded by an average of nearly 60,000-fold..., titers
[amounts] of infectious HIV-1 determined by quantitative endpoint dilution
culture of identical portions of plasma.”

Piatak M Jr et al. High levels of HIV-1 in plasma during all stages of
infection determined by competitive PCR. Science. 1993 Mar
19;259:1749-54.

“concordance [of viral load] with serology [ELISA/Western Blot antibody
tests] varied from 40 to 100%.”

Defer C et al. Multicenter quality control of polymerase chain reaction
for detection of HIV DNA. AIDS. 1992;6:659-63.

“we identified a group of 6 subjects who had been infected [with HIV]
through a single common [blood] donor...Throughout follow-up (range
6.8-10.1 years after infection), 5 of the [HIV antibody positive]
recipients and the donor...remained clinically free of symptoms, with
normal CD4 cell counts and no p24 antigenaemia. HIV-1 was isolated [via
co-culture, which is not really isolation] from only 1 recipient [in other
words, the only evidence of HIV was antibodies, all other measures
indicated no HIV and no AIDS]”

Learmont J et al. Long-term symptomless HIV-1 infection in recipients of
blood products from a single donor. Lancet. 1992;340:863-7.

“In blood donor studies in the developed world, about 20% of sera referred
to confirmatory laboratories give indeterminate western blot results,
almost all of which are on presumed negative specimens.”

Mortimer PP. The fallibility of HIV Western blot. Lancet. 1991 Feb
2;337:286-7.

“there were 16 sera from 30 viraemic patients which did not have
detectable p24 antigen (<5 pg/ml, Fig. 2). As a consequence, p24 antigen
concentration and HIV-1 RNA did not correlate well.”

Semple M et al. Direct measurement of viraemia in patients infected with
HIV-1 and its relationship to disease progression and zidovudine therapy.
J Med Virol. 1991;35:38-45.

“HIV was isolated [using co-culture] from only 36% of plasma samples, and
the isolation rate was closely related to CD4 cell counts, increasing
gradually from 0% in subjects with >800 [million] CD4 cells [per liter] to
88% in those with < 100 [million] CD4 cells [per liter]...The comparison
of p24 antigenaemia with plasma viral cultures was not clear-cut.
Concordant data were found in 62 subjects...while discordant data was
observed in 37”

Venet A et al. Correlation between CD4 cell counts and cellular and plasma
viral load in HIV-1-seropositive individuals. AIDS. 1991;5:283-8.

“Five patients who did not yield virus isolates [via co-culture] in a
total of 14 attempts all had virus present in 1 per 10,000 or more cells,
while five from whom virus was isolated in 11 of a total of 16 attempts
all had virus present in 1 per 3,000 or fewer cells.”

Simmonds P et al. Human Immunodeficiency Virus-infected individuals
contain provirus in small numbers of peripheral mononuclear cells and at
low copy numbers. J Virol. 1990 Feb;64(2):864-72.

“the specificity and sensitivity of PCR for detection of HIV DNA were 100%
(225/225 seronegative, low-risk individuals tested negative) and 94%
(67/71 seropositive individuals tested positive), respectively. In a
second study ... 7/474 (1.5%) antibody-negative specimens were found to be
positive [for HIV DNA], 149/151 (99%) antibody-positive specimens were
positive [for DNA], and 12/13 (92%) antibody-indeterminate specimens were
negative for HIV DNA”

Young KKY et al. Detection of HIV DNA in peripheral blood by the
polymerase chain reaction: a study of clinical applicability and
performance. AIDS. 1990;4:389-91.

“Overall, plasma viremia [as measured by culture] developed during
follow-up in 17 of 27 patients (63 percent) who initially did not have
viremia, and was sustained in 35 (88 percent) of the 40 patients who
initially had viremia...In only 45 percent of persons from whom we
isolated plasma-associated HIV was p24 antigen detected in plasma or
serum”

Coombs RW et al. Plasma viremia in human immunodeficiency virus infection.
NEJM. 1989 Dec 14;321(24):1626-31.

“100 ELISA-negative donors...were tested by WB [note that normally a
negative ELISA will not result in a Western Blot ‘confirmatory’ test]. 20
were WBi, with p24 being the predominant (70%) and generally the only
band. Among recipients of WBi blood, 36% were WBi in their 6 month
post-transfusion sample, but so were 42% of a control population that had
received only WB-negative blood. When serial samples from recipients with
a WB pattern were tested on two occasions, only 35% of results were
reproducible. No recipients of WBi blood became ELISA positive, true
positive for WB, positive for HIV-1 antigen, or positive for ELISA
reactivity against recombinant p24 or gp41. [PCR] was negative for gag and
env HIV-1 sequences in all donors and recipients. Thus WBi patterns are
exceedingly common in randomly selected donors and recipients”

Genesca J et al. What do Western Blot indeterminate patterns for Human
Immunodeficiency Virus mean in EIA-negative blood donors?. Lancet. 1989
Oct 28;II:1023-5.

“The eight persons at risk who were positive for anti-nef protein
antibodies were also positive for HIV DNA; five of the eight remained
anti-nef antibody positive and HIV seronegative (by ELISA and Western
blotting) and p24/25 antigen negative for eight months (one person...) and
four months (four people), respectively, after the detection of HIV DNA”

Ameisen JC et al. Persistent antibody response to HIV-1-infected
seronegative persons. NEJM. 1989 Jan 26;320(4):251-2.

“23 of 25 biopsies from HIV seropositive individuals were positive for HIV
DNA...An average of 0.0001 to 0.01 HIV DNA copies per cell was estimated
to be present in biopsies with follicular hyperplasia or involution. The
positive lymphoma biopsies contained approximately tenfold fewer HIV DNA.
In contrast, 19 of 20 biopsies from seronegative or low risk individuals
were negative for HIV DNA.”

Shibota D et al. Human immunodeficiency viral DNA is readily found in
lymph node biopsies from seropositive individuals. Am J Pathol.
1989;135:697.

“approximately 1 percent of all initial screening ELISAs were reactive, 50
percent of repeat ELISAs were reactive, and 30 to 40 percent of first
Western blot assays were reactive and diagnostic.”

Burke DS et al. Measurement of the false positive rate in a screening
program for human immunodeficiency virus infections. NEJM.
1988;319(15):961-4.

“Infectious virus was recovered from the serum of 20(25.6%) of [78
randomly selected, HIV+ individuals, or whom about 30% were asymptomatic]
and was generally present in low titers. Only undiluted serum (not a
tenfold dilution) yielded infectious virus...In one serum sample, 25,000
infectious particles per milliliter were detected as measured by end
dilution of the serum. This sample came from a clinically healthy
individual with very low levels of antibody to HIV[!]. Nine of the
positive serum samples came from 39 individuals whose PMCs [peripheral
blood mononuclear cells] were also tested. Virus was isolated [sic] from
the PMCs of approximately 50% of these individuals and one third also
yielded infectious virus in their serum. Three serum samples contained
infectious HIV without any virus being recovered from the individuals’
PMCs...These studies demonstrate further that not all seropositive
individuals have virus recoveraable from their PMCs and that isolation
from serum is not a common event”

Michaelis BA, Levy JA. Recovery of human immunodeficiency virus from serum
(letter). JAMA. 1987 Mar 13;257(10):1327.

“The sera [from 6720 blood donors] were examined by various enzyme-linked
immunoassay (ELISA) screening tests and, usually, by one of three types of
confirmatory assay. 45 samples (0.21%) were confirmed as positive. Only 2
were positive in all three confirmatory tests.”

Hunsmann G. HTLV-III antibody Positive Blood Donors. Lancet. 1985 May
25;1:1223.

False Positives

Although it is often denied, there is a lot of evidence that HIV tests can
generate false positives. In fact, with no proper validation of HIV tests,
it is not clear whether or not all positive HIV tests are false
positives.

“Kaushalya greets visitors with a warm welcome, hot tea and biscuits, but
her big dark eyes look sad. In the last three years, the 29-year-old woman
has lost her husband and social life. ''They broke our lives four years
ago,'' she says softly while other members of the family nod. The local
hospital said that Kaushalya's husband died of AIDS. Doctors at the
medical college in Rohtak city later explained that Kaushalya and her
daughter too had tested HIV-positive. The doctors pressured Kaushalya, who
was in her sixth month of pregnancy, to get an abortion because of her
HIV-infection. ''By telling me a lie they made me lose my only son,'' the
young widow mourns. But late last year, a second test [probably a Western
Blot or a second ELISA] showed that neither Kaushalya nor her daughter had
the AIDS virus. Other members of the family too have since been tested
negative for HIV. Like most Indian hospitals, the Rohtak hospital carried
out only a single HIV test [ELISA] on her husband. In most other nations,
at least three tests with similar results [two ELISA and one Western Blot]
are required before a patient is confirmed HIV-positive. However, her
family is still well known as 'the family of Chochi's first AIDS case.
''For years we lived with the trauma that the whole family was finished.
But it all was a big fraud,'' says Kaushalya's father-in- law Mangaram
Joon. ”

Oberhuber N. India:Village Still to Recover from AIDS 'Stigma'. Terraviva
Europe Daily Journal. 2001 Jan 15, http://www.ips.org/index.htm.

“Between January 1, 1989 and July 31, 1995, voluntary preoperative
screening tests for human immunodeficiency virus (HIV) infection, using an
enzyme-linked immunosorbant assay, were completed on 2,727 patients who
underwent elective orthopedic surgical procedures. There were 2,719
(99.7%) negative, 4 (0.15%) positive, and 3 (0.11%) false-positive
results; 1 test was indeterminate (0.04%)”

LaPorte DM et al. Human immunodeficiency virus testing for elective
orthopedic procedures: results in a community-based hospital. Orthopedics.
2001 Jan;24(1):52-5.

“Because of the RNA assay's 1.9% to 3.0% false-positive rate, results must
be carefully interpreted and compared to HIV-1 viral load levels seen
during proven HIV-1 seroconversion. We report the case of a sexually
active woman with symptoms suggestive of ARS who had a false-positive
HIV-1 RNA assay result.”

More D et al. Utility of an HIV-1 RNA assay in the diagnosis of acute
retroviral syndrome. S Med J. 2000 Oct;93(10):1004-6.

“Negative results (<50 copies/mL), were obtained in 30/32 (94%) [bDNA 3.0]
assays [meaning that false-positive results were obtained in 2/32 or 6% of
cases]”

Erice A et al. Performance characteristics of the bDNA 3.0 assy for
quantitation of HIV-1 RNA in plasma [abstract]. 7th Conf. Retroviruses and
Opp Infections. 2000 Jan 30-Feb 2.

“In 1984, I was informed that test results showed that I had an ‘HIV’
infection and I had at best five years to live...I am now 50 years old and
have taken back control of my own health. For the past eight years, I’ve
had no need for doctors, and have been on a diet of pure water, organic
food and a positive belief system.”

Anderson A. Letter. Alive. 2000.

“False positive and false negative results are to be expected [in HIV
antibody testing] as with all screening tests”

Zhang Z-Q et al. Sexual Transmission and Propagation of SIV and HIV in
Resting and Activated CD4+ T Cells. Science. 1999 Nov
12;286(5443):1353-7.

“We describe here a case of heterophile antibodies that are cross-reactive
with bovine and caprine proteins occurring in a 22-month-old child,
causing false-positive immunoassay results to human immunodeficiency virus
type 1 (HIV-1) and a number of other infectious serology tests...we
believe the positive test results observed in this patient were due to
heterophile antibodies reactive with BSA and caprine proteins. All of the
positive tests observed used BSA [bovine serum albumin] as a blocking
agent for the preparation of the microELISA reaction wells.”

Willman JH et al. Heterophile Antibodies to Bovine and Caprine Proteins
Causing False-Positive Human Immunodeficiency Virus Type 1 and Other
Enzyme-Linked Immunosorbent Assay Results. Clinical and Diagnostic
Laboratory Immunology. 1999 Jul;6(4):615-6.

“18 subjects had 1 or 2 positive results with v.2.0 and an undetectable
confirmatory test for a false positive rate of 4.4%. The rate is similar
at baseline (9/183 subjects = 4.9%), wk. 4 (7/162= 4.3%) and wk. 26 (2/44
= 4.5%). Of the 18 pos. specimens, 9 tested pos. once and 9 twice. With
version 3.0, 11 of 67 samples tested were pos. (16.4%). 6 were pos. once
and 5 twice. The range of false pos. rates was 9.1% at wk. 4 (total of 22
specimens) to 26.7% at wk. 26 (total of 15 specimens). A week 4 sample
with two values of 8,000 copies/ml on v.2.0 was neg. by DNA PCR, p24
antigen and Western Blot. Follow-up testing of this subject at wk. 26 was
negative for HIV antibody and RNA. Discussion: The emotional impact of a
false positive screening RNA test in a recently exposed person is
significant. With the high false positive rate, we do not advocate the
routine use of HIV RNA tests to screen asymptomatic people. The high rate
of repeat false positive tests in a given sample (50%) suggests a possible
biologic mechanism.”

Roland ME et al. Pitfalls of HIV RNA testing in the San Francisco
post-exposure prevention (PEP) project. Conf Retroviruses Opportunistic
Infect. 1999 Jan 31-Feb 4;6(101):Abstract no. 179.

“The Centers for Disease Control and Prevention (CDC) states that the two
tests used to identify HIV - the ELISA and the Western blot (WB) - used in
combination, have a better than 99% accuracy rate, but only if they are
performed repeatedly. (The exact rate is unknown and the CDC states that
it has no data on just how many false positives versus false negatives
occur!)…The CDC estimates that 0.6% of Americans are HIV-positive…Using
the CDC estimate that 0.6% of Americans are HIV-positive, in a population
of 10,000, 60 Americans would test positive! This 60 must include all the
false positives, 30, leaving only 30 people actually infected. This leads
to the following conclusion: using a 99% accuracy, one finds as many false
positives as true positives. Even if the results of both AIDS tests, the
ELISA and WB, are positive, the chances are only 50-50 that the individual
is infected.”

Stine GJ. Testing for Human Immunodeficiency. AIDS Update 1999.
1999;357-371.

“Results - Of 421 donors who were positive for HIV-1 by Western blot, 39
(9.3%) met the criteria of possible false positivity because they lacked
reactivity to p31. Of these, 20 (51.3%) were proven by PCR not to be
infected with HIV-1. The false-positive prevalence was 4.8% of Western
blot-positive donors and 0.0004% (1 in 251,000) of all donors (95%
confidence interval, 1 in 173,000 to 1 in 379,000)...A review of the 5.02
million donations in the 1991-1995 REDS donation database revealed that
4650 were anti-HIV EIA repeat-reactive and 421 were HIV-1 Western blot
positive (0.008% of all donations, 9.0% of EIA repeat-reactives) using the
1993 FDA interpretive criteria. Thirty-nine (9.3%) of the Western blots
with positive results lacked the p31 band.”

Kleinman S et al. False-positive HIV-1 test results in a low-risk
screening setting of voluntary blood donation. JAMA. 1998 Sep
23/30;280(12):1080-5.

“WB was considered diagnostic for HIV-1 if there was reactivity with two
of three envelope bands (gp160/120 and gp 41). The rate of HIV-1
false-positive ELISAs was…63.6%…among uninfected leprosy patients…Of the
cohort of 500 pregnant women, HIV-positive results were obtained by Abbott
ELISA in…5.6%, Organon ELISA in…5.4%, and on both tests for…5.2%…WB were
indeterminate in…83.6%…of 55 leprosy patients and...3.9%...of HIV-negative
pregnant women.”

Kashala O et al. Infection with human immunodeficiency virus type 1
(HIV-1) and human T cell lymphotropic viruses among leprosy patients and
contacts: correlation between HIV-1 cross-reactivity and antibodies to
lipoarabinomannan. JID. 1994 Feb;169:296-304.

“This gives a false-positive rate [on ELISA] of about 4% [manufacturer
quotes 0.58%]”

Challakeree K, Rapaport MH. False positive HIV-1 ELISA results in low risk
subjects. Western Journal of Medicine. 1993 Aug;159(2):214-5.

“In 1990, of 20.2 million HIV tests done in Russia only 112 were confirmed
and about 20,000 were false positives, 1991 saw some 30,000 false
positives out of 29.4 million tests, with only 66 confirmations.”

Voevodin A. HIV screening in Russia. Lancet. 1992;339:1548.

“HIV-1 p24 is the HIV-1 protein most prone to "false-positive"
reactions…false-positive reactions have been observed with every single
HIV-1 protein”

Ng V. Serological diagnosis with recombinant peptides/proteins. Clin Chem.
1991;37(10):1667-8.

“144 dog sera were tested on Chiron Western blot strips. Of these, 72 sera
(50%) reacted with one or more HIV recombinant proteins”

Strandstrom HV et al. Studies with canine sera that contain antibodies
which recognize human immunodeficiency virus structural proteins. Cancer
Res. 1990 Sep 1;50(17 Suppl):5628-5630.

“we found crossreacting antibodies...to HIV-1 in patients with multiple
sclerosis. Among 150 healthy Finnish persons, 1 (a woman) had antibodies
to p24 and p55 of HIV-1. Some patients with multiple sclerosis, cutaneous
T-cell lymphoma, or dermatologic disorders had antibodies that also
reacted with the viral proteins of an HIV-2 isolate”

Ranki A, Johansson E, Krohn K. Interpretation of antibodies reacting
solely with human retroviral core proteins. NEJM. 1988;318:448-9.

“Three chimpanzees were inoculated with AIDS plasma [i.e. plasma from
someone with AIDS, not purified virus] and one was inoculated only with
normal human plasma. Blood was sampled biweekly from each animal and serm
was tested in the standard indirect ELISA for HTLV-III [HIV]
antibodies...all four of the animals were positive for passively
transferred HTLV-III”

Saxinger WC, Gallo RC. Competitive ELISA for the detection of HTLV-III
antibodies. US Patent Office. 1987 Apr 28;4,661,445.

“These results, supported by previous reports of false seropositivity in
asymptomatic blood donors, emphasize the need to be certain of viral
antigen specificity when screening for HIV antibodies. We suggest that
blood banks use both HIV-infected and noninfected cell lines when
confirming seropositivity by the Western Blot test and that the presence
of bands on such tests not be automatically considered to indicate
positive status”

Roy S et al. Need for caution in interpretation of Western blot tests for
HIV. JAMA. 1987;257:1047.

“we tested 151,667 blood units by ELISA. 130 (8.6%) were confirmed
positive by WB (in that they reacted with different HIV proteins,
including gp41 and/or gp 110). 8 of these were false positive for gp18 and
23 were false positive for p25 [now known as p24]; in other words there
was 1 false positive by WB for about 4 true positives in our population of
blood donors and under our work conditions”

CouroucŽ A-M et al. False-positive Western blot tests reactions to human
immunodeficiency virus in blood donors. Lancet. 1986 Oct 18;2:921-2.

“Reactivity with [HIV proteins] p24 and/or gp41 has been suggested as a
minimum requirement for HIV seropositivity by WB [Western Blot]. While
testing ELISA positive serum from Swedish blood donors we detected 3 sera
with false-positive WB reactions to p24 and p55...The 3...had no risk
factors for HIV infection”

Biberfeld G et al. Blood donor sera with false-positive western blot
reactions to human immunodeficiency virus. Lancet. 1986 Aug 2;2:289-90.

“The frequences of false-positive reactions in a tricky panel of samples
from patients with autoimmune and acute viral diseases...were Abbott
9.5%...Organon 1.7%...Litton 1.0%...Behring 2.7%...Wellcome 0%...and
Pasteur 0%...The results of a 7th EIA (Dupont) were excluded from the
study at the company’s request.”

Reesink HW et al. Evaluation of six enzyme immunoassays for antibody
against human immunodeficiency virus. Lancet. 1986 Aug 30;2:483-6.

“Initial testing...revealed that [a 34-year old woman from rural Alabama]
was positive for HTLV-III [HIV] antibody by ELISA tests on two separate
occasions. Here serum was then sent for verification to the designated
commercial laboratory, where three repeat ELISAs were strongly
positive...as was a Western blot assay...In July 1985, the patient was
informed that her serum was positive for HTLV-III antibody...Her physical
examination was normal. Both she and her husband of 14 years denied any
homosexual or extramarital sexual encounters, intravenous drug abuse,
blood transfusions, or foreign travel. The patients T4:T8 [immune cell]
ratio was 2.1:1, with a normal lymphocyte count. Her husband and their
two-year-old son were both antibody negative by ELISA. More blood was
drawn from the patient...Western blot, radioimmunprecipitation, and
HTLV-III virus isolation studies were all negative. HTLV-III ELISAs were
repeated in two laboratories, and results from both were
positive...Western blot tests with positive bands at 24 and 41 kd [which
this woman had, plus two others] have been used as the ‘gold standard’ by
which other test results are judged to be falsely positive. Several
articles refer to the inevitability of false positive Western blots.”

Saag MS, Britz J. Asymptomatic blood donor with false-positive HTLV-III
western blot. NEJM. 1986 Jan 9;314(2):118.

“we recently sent identical proficiency panels to five large commercial
firms that offered HTLV-III [HIV] western blot testing...Four of the five
laboratories reported at least one false-positive test result. The six
false-positive results were all on different normal specimens...In the
absence of a 41-kd band, a blot must show both a 24-kd and a 55-kd band to
be deemed positive [by the US army]”

Burke DS et al. False-positive Western blot tests for antibodies to
HTLV-III. JAMA. 1986;256:347.

“68% to 89% of all repeatedly reactive ELISA tests are likely to represent
false positive results...each year we might expected to find 175 to 209
truly antibody-positive donors [in Minnesota] and between 371 and 1701
falsely positive donors among those who have repeatedly positive screening
tests”

Osterholm MT et al. Screening donated blood and plasma for HTLV-III
antibody: facing more than one crisis?. NEJM. 1985;312:1185-8.

“[during validation tests for HIV ELISA antibody tests] any positive ELISA
screening result among the blood donors could be assumed to represent
Òfalse-positivesÓ [but, if this same person later had the same test
outside the context of a validation study, it would be assumed to be a
true positive!]”

Weiss SH et al. Screening test for HTLV-III (AIDS agent) antibodies:
specificity, sensitivity, and applications. JAMA. 1985;253(2):221-5.

“Specimens were studied from a mother and her child, both with suspected
transient viremia. The mother had 2 and the infant 3 positive HIV-1
cultures, but subsequently both individuals became negative for HIV-1 by
nPCR, standard virus [co-]cultures, CD8+-depleted virus [co-]cultures, and
enzyme-linked immunsorbent assay. HIV-1 RNA and DNA were not detected in
two lymph nodes taken from the mother 3 and 4 years after the last
virus-positive [co-]culture. PCR amplifaction and DNA sequence of HIV-1
env sequences from the...culture supernatants were performed in separate
laboratories to eliminate the possibility of cross-contamination.
Phylogenetic analysis found that none of the five isolates were
genetically linked. Although it is imporbable, these 5 virus isolates
appear to have arisen from 5 separate incidents of specimen contamination
or mislabeling. This case remains enigmatic, however, in that both the
mother and infant had strong CD8+ cytotoxic lymphocyte proliferation to
multiple HIV-1 antigens”

Frenkel LM et al. Genetic Evaluation of Suspected Cases of Transient HIV-1
Infection of Infants. Science. 15 May 1998;280:1073-1077.

Negative HIV Tests with AIDS!

There are many cases of people with AIDS defining conditions, or at least
AIDS-defining low CD4 cell counts, who are continuously negative for HIV
antibodies. How can this be if HIV is the undisputed cause of AIDS? It
probably is not another virus, because these people are geographically
scattered. Could it be that HIV is not the cause of AIDS, but most people
with AIDS produce similar antibodies as a consequence of their illness?

“The syndrome of idiopathic CD4+ T lymphocytopenia is defined by the
Centers for Disease Control (1992) as cases which demonstrate depressed
numbers (<300/cubic millimeter) and proportions (<20% of total T cells) on
at least two consecutive occasions, with no laboratory evidence of HIV-1
or HIV-2 infection, and the absence of any defined primary or secondary
immunodeficiency disease or therapy associated with depressed levels of
CD4+ T lymphocytes...The patients have presented with a history of severe
or recurrent infections with intracellular pathogens or virus-associated
malignancies which, even before the description of AIDS, were recognised
as being highly suggestive of underlying deficiency of cell-mediated
immunity. Indeed, it was this constellation of clinical features...that
clearly identified the new clinical entity of AIDS”

Bird AG. Non-HIV AIDS: nature and strategies for its management. Journal
of Antimicrobial Chemotherapy. 1996;37(B):171-183.

“Recently, patients have been described with profound CD4+
T-lyphocytopenia [deficiency in CD4 immune cells] but without evident HIV
infection...We studied 12 patients with CD4+ T-lymphocytopenia...(10 men
and 2 women) [who] ranged in age from 30 to 69 years. Eight had risk
factors for HIV infection. The clinical manifestations were heterogeneous:
five patients had opportunistic infections, five had syndromes of unknown
cause, and two had no symptoms. Two patients died from acute complications
of their immunodeficiency.”

Ho DD et al. Idiopathic CD4+ T-Lymphocytopenia - Immunodeficiency without
evidence of HIV infection. NEJM. 1993 Feb 11;328(6):380-5.

“We interviewed 31 of the 47 patients identified with [HIV-negative AIDS,
involving low immune cell counts (lymphocytopenia) and no record of
positive HIV tests] and 23 of their contacts...Nineteen persons had
AIDS-defining illnesses (18 had opportunistic infections), 25 had
conditions that were not AIDS-defining [except for their low CD4 cell
counts] and 3 were asymptomatic...The investigation of contacts revealed
no evidence of a new transmissible agent that causes lymphocytopenia.”

Smith DK, Neal JJ, Homsberg SD. Unexplained opportunistic infections and
CD4+ T-lymphocytopenia without HIV infection. NEJM. 1993;328(6):373-9.

“One infant dying of histologically confirmed HIV encepalopathy was
repeatedly seronegative”

Kind C et al. Epidemiology of vertically transmitted HIV-1 infection in
Switzerland: results of a nationwide prospective study. Eur J Pediatr.
1992;151:442-8.

“A 5-month-old white girl having persistent oral candidiasis was brought
to medical attention because of acute respiratory distresss, pneumonia,
and hypoxia that worsened despite supportive care and antibiotics...The
diagnosis of AIDS was suspected, although ELISA and Western blot tests
were both negative for HIV antibody...The mother was HIV antibody positive
by ELISA and Western blot but belonged to no high-risk group and was
asymptomatic except for chronic diarrhea. The father was HIV antibody
negative...The patient...remains HIV negative [after 6 months]”

Goetz DW et al. Pediatric acquired immunodeficiency syndrome with negative
human immunodeficiency virus antibody response by enzyme-linked
immunosorbent assay and Western blot. Pediatrics. 1988;81:356-9.

“We have seen an infant, born to seropositive parents, who was
persistently seronegative for HIV antibody before the onset of severe
immunodeficiency..The diagnosis of AIDS in this child rests on the
opportunistic infections, decreased T4/T8 [immune cell] ratios, impaired
T-cell immunity, loss of functional antibody, and seropositivity in the
parents”

Marshall GS et al. AIDS in a child without antibody to HIV. Lancet.
1987;1:446-7.

“Among the 88 patients with AIDS tested, the HTLV-III [HIV] ELISA
indicated a positive result in 72 cases (82%)”

Weiss SH et al. Screening test for HTLV-III (AIDS agent) antibodies:
specificity, sensitivity, and applications. JAMA. 1985;253(2):221-5.

HIV Tests in Children

HIV tests in children are particularly problematic, because they get many
antibodies from their mothers, especially if they nurse. This has
significant consequences, because children will usually be assumed to at
risk, and denied the many benefits of breastfeeding, even though most will
end up HIV-negative at some point anyway.

“[the definition of HIV-uninfected in babies was] two negative
enzyme-linked immunosorbent assay results at 9 months or older among those
either not breastfed or who had stopped breastfeeding more than 3 months
before their last sample”

Coutsoudis A et al. Method of feeding and transmission of HIV-1 from
mothers to children by 15 months of age: prospective cohort study from
Durban, South Africa. AIDS. 2001 Feb 16;15(3):379-87.

“Although DNA and RNA PCR and cell culture can detect very low
concentrations of HIV-1, these assays yield a positive result in only
20-40% of vertically- infected infants who are tested shortly after
birth”

Dunn DT et al. Interventions to prevent vertical transmission of HIV-1:
effect on viral detection rate in early infant samples. AIDS. 2000 Jul
7;14(10):1421-8.

“Infants were considered to be HIV-1 infected if they had detectable HIV
RNA on two separate blood draws, or a reactive EIA [ELISA antibody test]
and confirmed by Western blotfor HIV-1 antibody at 18 months of age.
Infants who had a single positive plasma HIV-1 RNA test were considered to
have probable infection. Where possible, HIV culture...was also performed
to confirm the HIV-1 infection in the infants...At birth, one of 22
infants was HIV-1 infected. One infant, who tested negative, died the day
after birth leaving 21 evaluable infants for subsequent testing. At 6
months of age four of 21 infants were HIV-1 infected (one in cohort 1 and
three in cohort 2). One of the four HIV-infected infants was initially
positive for plasma HIV RNA at birth, two were initially HIV RNA positive
at 6 weeks of age, and one was initially HIV RNA positive at 6 months of
age. Two of the infants with positive plasma HIV RNA tests (one positive
at birth and the other positive at 6 weeks of age) also had a confirmatory
positive HIV culture; one infant had a confirmatory HIV RNA test. One of
these four infants had a single positive plasma HIV RNA test, but died
before a confirmatory test and was therefore considered as probably HIV-1
infected.”

Musoke P et al. A phase I/II study of the safety and pharmacokinetics of
nevirapine in HIV-1-infected pregnant Ugandan women and their neonates
(HIVNET 006). AIDS. 1999 Mar 11;13(4):479-86.

“At birth, 5 babies had a positive PCR...and 3 of them had detectable p24
antigenaemia...Among the 45 babies who were negative by PCR, 20 were
tested by HIV culture and all were negative. By 4-9 weeks of age, 16
infants had a positive PCR; 13 with the three primer sets, and 3 with two
primer sets. HIV culture could be done in 14 of these cases and was
positive in 11, negative in 1, and indeterminate in 2...By the age of 5-9
months...34 children previously found negative and 10 the 16 found
positive [were retested]. The results remained unchanged for PCR, and
culture was positive in the 2 children who had indeterminate results at
4-9 weeks. In addition, p24 antigenaemia became positive in 1 child
previously found infected...The negative results obtained at birth by PCR
and culture indicate that the viral load in PBMC is not sufficient to be
detected.”

Krivine A et al. HIV replication during the first few weeks of life.
Lancet. 1992;339:1187-9.

“[HIV co-culture] was positive in 32 of 41 (78%) [HIV-positive] children”

Kind C et al. Epidemiology of vertically transmitted HIV-1 infection in
Switzerland: results of a nationwide prospective study. Eur J Pediatr.
1992;151:442-8.

“Infants were defined as infected by a positive [i.e. p24 antigen present]
HIV-1 [co-]culture or by increasing anti-p24 or gp41/gp120 antibody titers
after delivery...Infants were defined as not infected if HIV-1 cultures
were negative, a sequential decline or loss of antibody to both p24 and
gp41/gp120 proteins was measured, and immunoglobulin levels and T
lymphocyte subset counts were comparable to those of control infants [no
word on whether some infants were indeterminate, or whether all were
arbitrarily placed in one category or the other]”

Hutto C et al. A hospital-based prospective study of perinatal infection
with human immunodeficiency virus type 1. J Pediatr. 1991;118:347-53.

“The detection of conventional IgG antibodies to HIV-1 during the first
year of life may result from the passive transfer of maternal
antibodies...Our inability to detect these antibodies in 10 of the 11
infants who were without evidence of AIDS in the first year of life but
who had positive cord-blood cultures highlights the difficulty of
diagnosing perinatal HIV-1 infection. The absence of detectable antibodies
in children with obvious clinical disease has also been noted in previous
studies”

Ryder RW et al. Perinatal Transmission of the Human Immunodeficiency Virus
Type 1 to Infants of Seropositive Women in Zaire. NEJM. 1989 Jun
22;320(25):1637-42.

“30 of the infants born to seropositive mothers reverted from seropositive
to seronegative. The median age of these 30 infants at seroreversion...was
9 months (range 1 to 16)”

Rogers MF et al. Use of the polymerase chain reaction for early detection
of the proviral sequences of human immunodeficiency virus in infants born
to seropositive mothers. NEJM. 1989 Jun 22;320(25):1649-54.

“proviral [HIV] sequences [of DNA] were detected in 9 of the 10 infants
tested whose illness met the CDC case definition for HIV infection, this
definition includes infants with AIDS, positive culture, positive serum
antigen [p24] test, or persistent antibody beyond 15 months of age. In
addition, proviral sequences were detected in one infant with nonspecicif
findings who was negative on culture and serum antigen testing and less
than 15 months of age”

Rogers MF et al. Use of the polymerase chain reaction for early detection
of the proviral sequences of human immunodeficiency virus in infants born
to seropositive mothers. NEJM. 1989 Jun 22;320(25):1649-54.

“HIV proviral sequences were detected in 1 or more serum specimens
obtained during the postnatal period from all of the 6 infants tested who
later had AIDS and from 4 of the 14 infants who had non-specific
findings”

Rogers MF et al. Use of the polymerase chain reaction for early detection
of the proviral sequences of human immunodeficiency virus in infants born
to seropositive mothers. NEJM. 1989 Jun 22;320(25):1649-54.

“In four of five infants who had signs or symptoms of HIV infection after
becoming seronegative, we detected evidence of HIV infection with use of
hybridization studies carried out after the genome was amplifieid with the
polymerase-chain-reaction method. One infant who became seronegative was
totally free of symptoms but carried the HIV genome”

Blanche S et al. A prospective study of infants born to women seropositive
for human immunodeficiency virus type 1. NEJM. 1989 Jun
22;320(25):1643-8.

“Of 1954 women screened at delivery, 12% were seropositive for HIV-1...At
labour none of the 109 seropositive mothers for whom follow up was
possible had AIDS...during two years of follow up, 4% developed AIDS, 28%
had AIDS related complex, 46% had generalized lymphadenopathy, and the
remaining 25 had no symptoms...Of 61 children who became seronegative at 8
months, antibodies to HIV-1 reappeared in nine at 12 months. By comparison
none of of the nine children who became seronegative at 12 months showed a
reappearance of antibodies. On the other hand, 18% of children who were
seropositive up to 12 months became negative at 18 months and were free of
symptoms after 24 months...of 13 neonates who were seronegative at birth,
four converted to become seropositive at different ages...HIV-1 serology
is unreliable among children under 18 months of life”

Hira SK et al. Perinatal transmission of HIV-1 in Zambia. BMJ.
1989;299:1250-.

Validation: Search for the Gold Standard

HIV tests should be validated against direct isolation of the virus from
people that test positive, and lack of isolation in people who test
negative. Instead of just comparing people with AIDS against healthy
people, tests should also be validated on people with non-AIDS diseases
that may cross-react (such as leprosy or malaria) and with other
conditions that may generate a higher load than normal of antibodies (e.g.
recent vaccination, pregnancy, auto-immune disease). Isolation should be
validated by purification of HIV particles, followed by microscope
verification of purity, and then by analysis of the constituent proteins
and genetic material.

“Primary infection was defined as a confirmed positive virologic test
result with either a negtaive HIV antibody assay result or an
indeterminate Western blot. Because there is no virologic gold standard,
we assumed that levels of plasma HIV RNA had a sensitivity of 100% for
diagnosing primary infection [bonus marks for detecting the flaw in this
logic].False-positive HIV RNA measurements were defined as those that were
negative on repeated testing and those obtained in patients who did not
undergo seroconversion [note the contradiction with the previous
sentence]...Eight of 303 uninfected patients (2.6%) had false-positive
results on HIV RNA testing”

Daar ES et al. Diagnosis of primary HIV-1 infection. Ann Int Med. 2001 Jan
2;134(1).

“At present there is no recognized standard for establishing the presence
and absence of HIV-1 antibody in human blood.”

Human Immunodeficiency Virus Type 1 HIVAB HIV-1 EIA. Abbott Laboratories.
1997 Jan.

“This study assumed that the investigated samples were from non-HIV
infected individuals. While we were unable to unequivocally prove this,
samples were obtained from normal blood donors who signed a declaration
form stating that they had not engaged in any HIV-related risk behaviour.
Because these individuals were healthy enough to present for blood
donation, it is unlikely that their indeterminant WB reactivities could
have resulted from the loss of anti-core antibodies, which has been
associated with late-stage AIDS...the use of WB interpretive criteria,
such as those proposed by the World Health Organization [would] allow
individuals reactive to two glycoprotein bands to be considered
anti-HIV-1-seropositive, and would inappropriately classify 11 out of the
13 samples described in this study as anti-HIV-1-seropositive by the DB
[Diagnostic Biotechnology] WB”

Healey DS, Bolton WV. Apparent HIV-1 glyco-protein reactivity on Western
Blot in uninfected blood donors. AIDS. 1993;7:655-8.

“Alloimmune mice...were shown to make antibodies against gp120 and p24 of
human immunodeficiency virus (HIV), and mice of [two] autoimmune
strains...made antibodies against gp120. This is surprising because the
mice were not exposed to HIV. [i.e. HIV proteins are found in uninfected
mice!!]”

Kion TA, Hoffmann GW. Anti-HIV and anti-anti-MHC antibodies in alloimmune
and autoimmune mice. Science. 1991 Sep 6;253:1138-40.

“Serologic assays identify persons with prior exposure to human
immunodeficiency virus (HIV-1), they do not specifically determine current
infection...The number of peripheral blood lymphocytes expressing viral
RNA, as detected by in situ hybridization in an infected person is less
than 1 in 10,000 cells...Defective provirus would be detected by the PCR
technique provided the region targeted for amplification was preserved
[i.e. antibody tests do not prove current infection, and viral load/PCR
tests cannot distinguish between defective and infectious HIV!]”

Ou CY et al. DNA amplification for direct detection of HIV-1 in DNA of
peripheral blood mononuclear cells. Science. 1988 Jan 15;239(4837):295-7.

“for HIV infection, there is no independent, unequivocal way of
identifying a group of individuals who are all assuredly infected or
uninfected”

Cleary PD et al. Compulsory premarital screening for the human
immunodeficiency virus: Technical and public health considerations. JAMA.
1987;258:1757-62.

“The meaning of positive tests will depend on the joint [ELISA/WB] false
positive rate. Because we lack a gold standard, we do not know what that
rate is now. We cannot know what it will be in a large-scale screening
program”

Meyer KB, Pauker SG. Screening for HIV: can we afford the false positive
rate?. NEJM. 1987;317(4):238-41.

“We evaluated the validity of the test by determining whether the test
could distinguish known patients with AIDS from the normal population and
from groups that might pose cross-reactivity problems [but not against
actual detection of a virus]...Since the ELISA [antibody test] ratio
[indicating the intensity of the antibody reaction] was less than 5.0 in
approximately 99% of these controls, serum samples with ratios of 5.0 or
greater were defined as positive for HTLV-III [HIV] antibodies”

Weiss SH et al. Screening test for HTLV-III (AIDS agent) antibodies:
specificity, sensitivity, and applications. JAMA. 1985;253(2):221-5.

Surrogate Markers

Surrogate Markers are lab measurements that substitute for real measures
of health. The commonest surrogate markers used in HIV/AIDS research are
CD4/CD8 cell counts/ratios and Viral Load. Decisions made on the basis of
these lab counts should be interpreted with caution, particularly
decisions that could prove damaging, such as starting antiretroviral
medications in a healthy person.

“until controlled trials are able to prove the utility of an undetectable
viral load as a surrogate marker for clinically relevant outcomes in
heavily pre-treated patients, we bleieve that clinicians should show
caution before striving for complete viral suppression at any cost”

Deeks SG, Martin JN. Editorial Comment: Reassessing the goal of
antiretroviral therapy in the heavily pre-treated HIV-infected patient.
AIDS. 2001;15(1):117-9.

“Significant improvements in CD4 cell count and plasma HIV RNA in
recipients of IL-2 relative to control patients were associated with a
nonsignificant trend toward improved clinical outcome [normally
statistically insignificant trends are ignored, but if you really, really
want to believe that your therapy is working...]”

Emery S et al. Pooled Analysis of 3 Randomized, Controlled Trials of
Interleukin-2 Therapy in Adult Human Immunodeficiency Virus Type 1
Disease. JID. 2000 Aug;182(2):428-434.

“CD4 and CD8 T cell counts, and HIV-1 plasma v iremia were quaantitated
before, during, and after episodes of STI [Sexually Transmitted
Infections]. Increases in...viremia [viral load] and a decline in CD4+ T
cell counts occurred during gonococcal cervicitis and returned to baseline
after treatment...Similar changes were seen in women with pelvic
inflammatory disease. Acute bacterial STI resulted in increased HIV-1
viremia”

Anzala AO et al. Acute Sexually Transmitted Infections Increase Human
Immunodeficiency Virus Type 1 Plasma Viremia, Increase Plasma Type 2
Cytokines, and Decrease CD4 Cell Counts. JID. 2000 Aug;182(2):459-466.

“The clinical state (if the person is without symptoms) is not a major
detriment [to administering anti-HIV drugs]: it is the [viral load
surrogate marker] numbers that appear to decide the therapeutic course. I
take issue with that approach...These drugs can be toxic and can be
directly detrimental to a natural immune response to HIV…. This effective
antiviral immune response is characteristic of long-term survivors
who…have not been on any therapy. …[T]he current antiviral therapies…do
not bring about the results achieved by a natural host anti-HIV response.
This immune response, observed in long-term survivors, maintains control
of HIV replication without the need for antiviral treatment.”

Levy JA. Caution: should we be treating HIV infection early?. Lancet. 1998
Sep 19;352:982-3.

“surrogate end points have been misleading about the actual effects that
treatments have on the health of patients...Surrogate end points are
rarely, if ever, adequate substitutes for the definitive clinical outcome
in phase 3 trials”

Fleming TR, DeMets DL. Surrogate End Points in Clinical Trials: Are We
Being Misled?. Ann Int Med. 1996 Oct 1;125(7):605-13.

“At present there is no convincing evidence that the current surrogate
markers [including CD4, CD8, viral load measurements] can be reliably used
to predict the clinical efficacy of new treatments.”

Peto T. Surrogate markers in HIV disease. Journal of Antimicrobial
Chemotherapy. 1996 May;37 (Suppl. B):161-170.

CD4/CD8 Cell Counts

Low CD4 cell counts (or abnormal CD4/CD8 ratios) are considered to be an
unambiguous sign of the progression of AIDS, yet science does not support
this. There are people with AIDS with normal CD4 cell counts and healthy
people with low CD4 cell counts. Over a large group of people, it may well
be true that on average, low CD4 cell counts identify a group of people
who are more likely to be in ill health, but this logic does not apply to
all individuals. Furthermore, even if low CD4 cell counts were always
associated with ill health, it would not necessarily follow that
artificially raising these counts with toxic drugs would be beneficial.

CD4 cell counts are a type of Surrogate Marker, a lab measurement that
substitutes for a real measure of health. Consequently, decisions made on
the basis of CD4 cell counts should be interpreted with caution,
particularly decisions that could prove damaging, such as starting
antiretroviral medications.

“Two years before the virus that causes AIDS was discovered, physicians in
the United States and Europe realized that the defining symptom of the
mysterious new disease was the loss of a specific immune system cell
population, called CD4 cells. Twenty years later scientists still don't
know what kills the cells [but, gee, we all thought it was HIV!]. And its
eventual discovery will be key to understanding AIDS - defined as a rise
in the numbers of viruses in the bloodstream coupled with a fall in the
CD4 cell count. [However]...it is not in HIV's interests to kill off its
"home" [CD4] cell, most scientists believe a complex interaction is at
play, causing the cells' deaths [translation: HIV doesn’t kill CD4 cells
and therefore cannot be the cause of AIDS]”

Garrett L. Immune cell deaths still a stubborn puzzle. Newsday. 2001 Jun
5;C08.

“Declining host selenium levels...inhibit CD4 T cell production, which
permits opportunistic infectious pathogens to proliferate. These pathogens
in turn lead to further depression of serum selenium levels and associated
decline in CD4 T cell count”

Foster HD. AIDS and the Selenium-CD4 T Cell Tailspin, the geography of a
pandemic. Townsend Letter. 2000 Dec;94-9.

“HIV-1 infects CD4+ T cells but direct infection and killing of these
cells can only partly account for HIV-1-associated lymphocyte depletion.
The actual number of productively infected cells is estimated to be
relatively low, in the order of 5 X 10^7 to 5 X 10^8 CD4+ T cells whereas
the human body contains an average of 2.5 X 10^11 CD4+ T cells. Direct
infection of CD4+ T cells does not explain the loss of naive CD8+ T cells
that parallels the decline in naive CD4+ T cells during asymptomatic HIV-1
infection.

More important in this respect may be the response of the immune system.
HIV-1 activates the immune system persistently because of high and
continuous virion production and possibly by viral gene products such as
Nef.”

Mette D et al. T cell depletion in HIV-1 infection: how CD4+ cells go out
of stock. Nature Immunology. 2000 Oct;1:285-9.

“Previously published data on CD4 cell count changes during therapy
interruptions have mainly consisted of reports on very small numbers, but
there has been a tendency to observe a distinct fall in numbers. The
relatively rapid early fall in CD4 cell count after interrupting therapy
may correspond to the relatively rapid increase in CD4 cell count after
initiating therapy, which has been ascribed to the redistribution of cells
from the lymphoid tissue [i.e. CD4 cells may not be increased with
antiretroviral therapy, merely shuffled around the body to places where
they are easier to measure]”

Youle M et al. (title missing). AIDS. 2000 Aug 18;14:1717-1720.

“The data should also serve as a strong reminder that using the CD4+ cell
count as a surrogate for HIV testing has a risk of markedly overestimating
the diagnosis of HIV. Therefore, CD4+ cell counts should not be relied on
for a presumptive diagnosis of HIV in lieu of consent for serologic
testing. Finally, a larger study of CD4+ cell counts in critically ill
individuals might better define the prognostic value of a low result.”

Aldrich J et al. The Effect of Acute Severe Illness on CD4+ Lymphocyte
Counts in Nonimmunocompromised Patients Ê. Arch Intern Med. 2000 Mar
13;160(5):715-6,
archinte.ama-assn.org/issues/v160n5/full/ilt0313-6.html#rc1r2.

“Several of the features of Leishmania infection are reminiscent of HIV
infection. In both, there is a decrease of CD4 lymphocytes, the immune
activation profile is similar, and a dominant TH2 profile is present...All
helminthic infections are associated with strong chronic immune
responses...[including] dcreased CD4 and CD4:CD8 ratios”

Bentwich et al. EDITORIAL REVIEW: Concurrent infections and HIV
pathogenesis. AIDS. 2000;14:2071-81.

“Controversy continues regarding the effects of HAART on CD4 T-cell
production...our understanding the mechanisms that lead to depletion of
CD4 T cells remains incomplete. The observation that T-cell turnover in
SIV-infected mangabeys appears to be normal, despite high viral loads, has
reinforced the hypothesis that indirect mechanisms may be largely
responsible for increases in T-cell turnover, yet there is little solid
evidence on how HIV and SIV mediate this effect [translation: we don’t
have a clue how HIV kills CD4 cells]”

Johnson RP. The dynamics of T-Lymhyocte turnover in AIDS. AIDS.
2000;14(suppl 3):S3-9.

“Tenfold (1 log10) incremental increases in maternal HIV RNA were
associated with a 1.9-fold increase (95% confidence interval [CI],
1.2-2.9) in transmission and a 2.1-fold increase (95% CI, 1.3-3.5) in
infant mortality (P<.01). Maternal CD4 cell counts and demographic and
medical characteristics were not significant predictors of transmission.
However, maternal CD4 cell counts below the median (400/mm3) were
significantly associated with infant mortality (P=.035, Fisher's exact
test) [i.e. CD4 cell counts might predict ill-health, but don’t seem to be
particularly associated with HIV/AIDS]”

Katzenstein DA et al. Serum Level of Maternal Human Immunodeficiency Virus
(HIV) RNA, Infant Mortality, and Vertical Transmission of HIV in Zimbabwe.
JID. 1999 Jun;179(6):1382-7.

“breast-fed [healthy, HIV-negative] infants had fewer CD4 T cells and a
great number of NK [natural killer] cells than the age-matched formula-fed
infants...suggesting greater maturity in the development of the immune
system of breast-fed infants”

Hawkes JS et al. The effect of breast feeding on lymphocyte subpopulations
in healthy term infants at 6 months of age. Pediatr Res. 1999
May;45(5):648-51.

“This analysis confirms that the rate of removal of CD4+ T cells is indeed
elevated and the half-life is indeed shortened in the HAART group [i.e.
therapy might raise the level of CD4+ cell counts, but they are not the
same as normal immune cells, and might not be doing any good]”

Hellerstein M et al. Directly measured kinetics of circulating T
lymphocytes in normal and HIV-1 infected humans. Nat Med. 1999
Jan;5(1):83-9.

“During HIV infection, CD4+-cell numbers and CD4/CD8 ratios decline in the
blood. This is usually attributed to direct viral killing or to other
indirect mechanisms. However, current models generally assume that such
changes in the blood are representative of changes in total CD4+-cell
numbers throughout the body. This article discusses the importance of
alterations in CD4+- and CD8+-cell migration in regulating blood
lymphocyte levels and questions the extent of virus-mediated CD4+-cell
destruction”

Rosenberg YJ, Anderson AO, Pabst R. HIV-induced decline in blood CD4/CD8
ratios: viral killing or altered lymphocyte trafficking?. Immunology
Today. 1998;19:10-17.

“Although progression to AIDS has generally been believed to be related to
exhaustion of the capacity for CD4+ T-cell renewal due to persistently
enhanced CD4+ T-cell turnover, this view is now increasingly being
challenged. This paper discusses these new experimental findings and
proposes alternative explanations for CD4+ T-cell depletion in human HIV-1
infection.”

Wolthers KC et al. Rapid CD4+ T-cell turnover in HIV-1 infection: a
paradigm revisited. Immunology Today. 1998;19:44-48.

“Margolick...and, independently, Adleman and Wofsy proposed the BH [Blind
Homeostasis] hypothesis. They postulated that, normally, a constant number
of T lymphocytes is maintained regardless of the CD4-toCD8 ratio...[and]
would necessarily lead to a progressive depletion of the CD4 compartment
in HIV infection if CD4 cells are preferentially destroyed by the
virus...[based on the detailed analysis in this paper] we consider the
original BH hypothesis and also its more elaborate version to be
biologically rather implausible...If correct, the BH hypotheses, but not
the alternative hypothesis, could account for CD4 cell depletion by HIV.
However, as we have discussed, there is no compelling evidence in favor of
BH, either inherent or HIV imposed...these considerations also suggest a
need to reevaluate current concepts about HIV pathogenesis, including the
concept that a systemic depletion of CD4 T cells is the hallmark of the
disease.”

Grossman Z et al. Conservation of total T-cell counts during HIV
infection: alternative hypotheses and implications. JAIDS.
1998;17(5):450-7.

“The summary of results from a 1993 state-of-the-art conference shows that
the effect of treatment on the most popular surrogate, the CD4 cell count,
did not accurately predict the effect of treatment on the clinical
outcomes, that is, progression to AIDS or time to death”

Fleming TR, DeMets DL. Surrogate End Points in Clinical Trials: Are We
Being Misled?. Ann Int Med. 1996 Oct 1;125(7):605-13.

“The CDC definition of idiopathic CD4 lymphocytopenia [HIV-free AIDS] does
not include any clinical parameters. [One group] comprises a series of
individuals...who have CD4