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Follow-Up To "When To Start Meds"
Jun 19, 2011

I was just reading this question to you. The questioner gave his/her labs since 2009, which all looked good to me as someone who isn't an expert. The latest labs from the person were 04/2010- cd4 829 cd4% 28 vl 29074. I believe they may have meant 2011 instead of 2010.

Anyway, these numbers looked good to me and even looked a lot like my own--which explains my interest. You told the person you agreed with their doc that meds will probably be needed sooner than later as their percentage was not in line with their absolute CD4. I don't mean to put you on the spot, but I thought it was important to ask because patients often get confused by different responses. I understand there are nuances at play and everything isn't black and white.

About 2 years ago now, I asked you about my labs. My CD4 has always been in the 650-800 range, vl around 9,000 to 15,000, and CD4% jumping from 21 to 27%--back and forth but usually towards the upper 20's. At that time, you said I was doing a good job controlling the virus on my own and meds weren't necessary in the near future. Now, I did say I was infected in 2001. I'm just wondering if the different responses were due to my labs being stable over time--no dramatic decreases in CD4 or CD4%. The questioner started with 39% and had dropped to 28% in 2 years. I'm just curious whether your thinking has changed and you would now tell me the same thing--my CD4 is not in line with my CD4%? It is so confusing. Treatment guidelines always seem to be based on CD4 and the percentage is rarely mentioned unless it is really low. But, we all keep reading about the percentage as a more reliable marker. Having said that, most docs still only talk about absolute CD4 as to when to begin meds. For example, my last labs were CD4 770, vl 11k, at 25%. My doc said I was doing great and no need to discuss meds now. But, I have been concerned about my percentage.

Response from Dr. Holodniy

Great question. I haven't changed my thinking dramatically, and your case differs because of time and stability. I am more concerned about the significant reduction in CD4% in 2 years in the face of detectable viral load, then a relatively stable CD4%/count over 10 years in the face of detectable viral load. There has been a slight change in thinking among experts though in the last year or so. About half of the experts would start treatment in anyone with a CD4 count >500 and any detectable viral load, and about half would not. In general I fall in the latter camp, but weigh each case individually and trends over time are important.



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