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Also responding to VRL and AIDS July 23:
Jul 27, 2010

I also presented late, unfortunately, with a CD4 of ZERO and a VRL of 650,524 and, for the most part, at this point in time, living a normal life and have been feeling quite good actually! I wanted to also give hope to the other writer!

I wrote you before and you kindly answered and I greatly appreciated it and will make another donation to your foundation.

I am a Gay Male,50, and was hospitalized for a month in March of 2008 with PCP Pnuemonia, Histoplasmosis (Disseminated) and MAC. I also had thrombocytopenia and neuropathy.

In April of 2008 I had my first visit to the hospital's ID clinic (Veteran's Administration) (Which has been wonderful btw) 4/2008: CD4 6 VRL 15,315 Was put on Atripla, Clarithamyacin, Ethambutol, Dapsone, Gabapentin and Itraconazole. 5/08 = CD4 60 VRL 244 8/08 = CD4 83 VRL Undet. (<40) 11/08= CD4 113 VRL Undet. CD4 % 5 Platelets 114,000 02/09 CD4 = 116 VRL = Undet. (was taken off of Clarith/Ethambutol) CD4 % 7 Platelets 126,000 05/09 CD4 = 166 VRL = 80 CD4 % 7 Platelets 171,000 08/09 CD4 = 175 VRL = 228 CD4 % 9 12/09 CD4 = 158 VRL = 188 CD4 % 8 03/10 CD4 = 234 VRL = 81 CD4 % 10 06/10 CD4 = 208 VRL = Undet. (YEAHHHHHHHHHHHHHHHHHHHHHHHHH!) CD4 % 9 (Liver Function Test ALL GOOD ALT AND AST) CBC RED = 3.80 and WHITE = 8.6 Cholesterol (HDL AND LDL) Normal Range Triglycerides Normal Range Sodium/Potassium/Glucose all NORMAL :)

Now a couple of questions if I may please:

1) Any idea why I had 3 undet tests in a row, then 3 detectable tests and then back to undetectable. No change in regimen and 100 per cent adherance to ATRIPLA. (A few times I took it late due to work, but I don't think I ever missed a daily dose)

2) Even though my last two CD4 tests were above 200, I am told that I should remain on DAPSONE until my CD4 per centage reaches 14. Do you concur?

3) I have done a lot of reading on Histoplasmois (since it almost killed me) and there seems to be some confusion in the literature (or perhaps I am the one confused) on when I can be taken off of Chronic Maintenance Therapy (ITRACONAZOLE) I was on 400 mgs a day which has now been reduced to 200 mgs a day. Now some of the sites say I should remain on lifetime supressive therapy and others say that it should be save to discontinue secondary prophlyaxis if on HAART with CD4 >150 for 6 months. I just read the CDC guidelines for the treatment of OI's in Adults and it appears it would be safe to discontinue the itra but the study cited only involved 32 patients. So, what do you think?

Thanks so much Dr. Frascino for all you do. I have enjoyed reading your answers to others questions and your blogs.....and love the wit!

Response from Dr. Frascino

Hi,

Thanks for taking the time to write in and share your encouraging story!

1. Your four detectable viral load tests were all only slightly elevated (80, 228, 188, 81). This may have been due to an intercurrent illness, vaccination or any of a number of other factors. If you had developed resistance to one or more of the drugs in your Atripla, we would have expected the viral load to continue to rise. That you are now once again undetectable (YEAH!) is indeed excellent news. Should your HIV plasma viral load increase to over 500, you should get an HIV resistance test (genotype and phenotype). For now I'd hold tight and hope for additional immune reconstitution (increase in absolute CD4 count and CD4%).

2. Yes, absolutely. There are two criteria for discontinuing secondary PCP prophylaxis. A CD4 count over 200 and a CD4% over 14% for greater than three months.

3. Although folks receiving secondary prophylaxis (chronic maintenance therapy) for histoplasmosis might be only low risk for recurrence of systemic histoplasmosis when their CD4 count increases above 100 in response to effective combination antiretroviral therapy, the number of patients who have been formally evaluated to date is insufficient to warrant a general recommendation to discontinue prophylaxis, in my opinion. I'd suggest you continue itraconazole for now.

Thanks for your kind comments and ongoing support of The Robert James Frascino AIDS Foundation (www.concertedeffort.org). Both are warmly appreciated.

Be well. Stay well.

Dr. Bob


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