Dear Dr. McGowan,

I have assumed that everyone with HIV would die at some point, if meds weren't started. It made me wonder about something. Does everyone eventually die without meds? Are there some who never progress to AIDS? If so, do you know the statistics?

Also, I've read that when CD-4 gets down below 200, you get all kinds of OIs. Is this just an average number? Or, can some get something like PCP at CD-4 250 or 300?

This was just something I got to thinking about. I first wondered why people back in the 80's didn't do the bubble-boy thing to protect themselves. From what I've learned, I guess no bubble can protect you from diseases and cancers once CD-4 fails.

Okay, thanks in advance for your response. Again, I'm just curious. I wouldn't think about going without meds.

Thanks for your very thoughtful questions.

Let me try to answer.

We used to think that HIV would lie dormant for years and then pop up and cause disease and death. In the mid-90s we started to measure the level of HIV in the blood and found that in most people the virus is very active from day 1, copying itself and producing lots of virus every day. This steady burden of virus would wear down the immune system and eventually cause AIDS.

On average, it takes about 10 years from the time of infection until AIDS develops without treatment. "On average" means that about half of the people will get sick by 10 years but the other will not be sick yet even after 10 years. Eventually most will get sick because the virus remains active and can damage the immune system even if it is slowly.

The best predictor of how fast a person will get sick and drop their CD4 count is their viral load -- the higher the viral load, the faster the progression.

There are people whose viral load is very low, even undetectable, without being on meds. We call them "long-term non-progressors" or "elite controllers" (if they are undetectable). These are about 1 to 2% of people with HIV. Their immune system has developed a balance with their virus to keep things stable...they may lose as many cells as they make. Recent studies have shown that some elite controllers may still lose CD4 cells over time, even though their virus remains undetectable. This may be due to the inflammation that occurs from having a chronic untreated infection. We have learned that many diseases (such as heart, kidney, liver, diabetes and bone disease) occur more commonly in people with HIV (even without being on medicine). These diseases may be caused by the activation (or inflammation) in the immune system caused by having HIV in the body. The liver and kidneys, etc get collateral damage (to borrow a phrase from the gulf war) from all this activity of the immune system.

Regarding PCP and other AIDS-related conditions. It is true that they could occur at higher CD4 counts. Most occur below 200, but the risk is many fold higher when the counts are below 50. So it is a continuous line with increasing risk the lower the CD4 count gets.

Living in a bubble wouldn't help for many of these infections because they can come from within our bodies from infections that have been put to sleep by our immune system that can then "wake up" when the CD4 count gets low. Infections like shingles, for example, is chicken pox virus that may stay in your body from childhood, or toxoplasmosis (a brain infection) or CMV (a virus that can damage the eyes and other organs) which can be picked up years before they cause problems related to AIDS.

Sorry for being so long winded.

Joe