I've been diagnosed hiv+ ten years. No meds yet, cd4 two hundred, viral load five thousand. I picked up a verucca on each foot about 2 years ago. Despite continuous treatment with various gels, creams etc from my doctor, and a month of cryo, they still remain and are getting bigger and more painful all the time. One is now as big as a 10pence piece. My consultant says that my low cd4 is to blame and that starting combination therapy would help get rid of them. I'm very reluctant to start just yet. I'd rather just get rid of the veruccas'. Do you know if there is any way I can get rid of them? Tanx RK

Hello RK,

The aggressive nature of your warts is indeed a reflection of your deteriorating immune system. Can you get rid of them? I'm not certain, but if they are in a location that is amenable to surgical removal, either with laser or scalpel, then you may be in luck.

If your CD4 count is hovering around 200, I, too, would encourage you to consider starting antiretroviral therapy, even though your viral load is still quite low (5000). The CD4 count is a measure of how much damage has been done to your immune system, and to a certain degree, how well you can expect your immune system to protect and fight for you. The persistent verruca that are not responding to the usual treatments are a warning sign that your immune system isn't functioning as well as it should When CD4s fall to 200, there is also a greater risk of getting more significant opportunistic infections, such as PCP (pneumocystis carinii pneumonia. Prophylaxis with the antibiotic Bactrim DS can help prevent this. Only you, with the help of your AIDS specialist, can decide when the time is right to start medications. One point to keep in mind is that there is a point at which the immune system can not significantly recover, and instituting antiviral medications after that point most likely will not lead to the same degree of immune reconstitution that you would have had if you had started earlier.

All major guidelines now recommend starting therapy when CD4s fall to the 250-350 range. I think you should very seriously consider starting potent therapy very soon, not because of the verruca, but to protect and rebuild your immune system in order to protect you from far more dangerous opportunistic infections. They are called "opportunistic," because they take the opportunity that your depressed immune system provides to manifest themselves and cause trouble. These infections can not bother us if the immune system is strong enough to ward them off. If they do get a foothold, they further knock down the already struggling immune system, which allows for the invasions of other unwanted opportunistic infections or malignancies.

I'm certainly not trying to scare you. I just want you to know that from a risk-benefit standpoint, your risks are greatly increased and the potential benefits of therapy are significantly decreased when CD4s decline to the 200-range and therapy is delayed. I understand your reluctance to start medications, but RK, I really believe now may be the BEST time. Only you can decide if it's the RIGHT time for you.

Stay well,

Dr. Bob