Do I have immune control?
Mar 13, 2002
Dr Cal, I began HAART within a month of infection with a VL of 4.5 million and a CD4 of 428 (26). I became undetectable and my CD4 rose to 950 (43). After 19 months I decided to try an STI or two. There are no clinical trails where I live, so it was just me and my doctor (plus thebody.com and a couple of other websites).
Three months after my first STI the VL was 1K. At six months it was 33K and I went back on meds for three months. Three months later the it was 12K, and at six 11K. CD4s were 725, 603, 482 and 605, respectively. CD4 percents--35, 24, 25 and 24. Genotype tests showed no resistance.
So has my STI been a success? Have I gained 'immune control' over the virus? Doesn't everyone have some degree of control? I think 11K is pretty good but isn't <5K the standard in Boston? Is there much difference between 5K and 11K in terms of progression? Will I lose my HIV specific immunity if I don't keep using meds periodically? I know they are doing studies to answer all these questions, but I'm dealing with this now.
Response from Dr. Cohen
Well, as with most issues in HIV, there is uncertainty in this initial phase of exploration. But there are still a few lessons to learn from.
First - I am not sure but will assume that the results you give for viral loads / Cd4 counts are done after you've stopped meds, not while on them. Since a viral load of 12K after being on meds for three months would clearly suggest a failure to resuppress. But given what I think you mean - I'll assume the viral loads are off meds - especially with no evidence of geno resistance.
So - since you mention 5K - where does 5 thousand as a goal of success come from? It is clear that there is no sharp line above which we would agree to call this a failure, below a success. Viral load measures are a continuum of the balance of immune control and viral growth. And there are judgements that are made when designing studies to decide what we'll call a success or not. And some of it comes from the treatment guidelines which used to suggest that anyone with a viral load of 5K or less would not need treatment - and thus if an STI protocol got you there - it could be a success by that guide. Ten thousand is similar in that it is good news - you don't need treatment with that low a viral load. So yes, you are in a good position right now to just monitor off meds.
So - does the STI you did deserve the credit??? The reason we can't be sure of the strategy of STI at this point is precisely the point you raise - everyone can have some degree of immune control. And in the pre-STI era - there are a fair percent of those who, without any treatment, have a viral load of 12K. Maybe 10% or more would have this degree of control just by the balance of the normal immune system and the virus. And so this makes it much harder to know if the STI pattern you have followed deserves the credit for why your viral load is about 10K. It may have been similar to this without these manipulations. Even with a seroconversion viral load of 4 million - we can't predict where the actual set point will be.
Now - the lower the set point seen after the STI strategy, the more the STI may deserve credit - since it is rare to have low viral loads "spontaneously". If for example, we had 20 people do an STI in the ways you describe - and 15 would have a viral load of below, say, 5K - everyone would be impressed since, without an STI strategy, we would expect maybe one or two to have that low of a viral load off meds. If we instead used 10K as the goal, it would be much less surprising if 4 of the 20 had achieved that viral load after STIs -- since this might be about how many would have this viral load if we did nothing. And so we can say that you are in a good, safe place. We can't know if the STI deserves the credit. One consideration is that it seems your viral load set point is lower after the second STI - 11K - than it was the first time - 33K at six months. It is these observations that continues to fuel interest - since this trend downward is encouraging. So - what would happen if you kept going is an open question - perhaps a few more rounds and you'd be even lower. Maybe.
In sum, there isn't much true difference of 5K and 11K - the rates of progression and immune damage are low with both counts. But the lower the better - 1K is likely better than 5K and so on... so we always keep trying to do what we can to get to lower counts. If we can. But you can certainly let it ride as is. We certainly don't know for sure if allowing a count of 11K will result in immune loss over time - again, we are all pretty new at this. But the concern is still generally true - indefinite stalemates with our immune system and HIV are rare events - the lower the viral load, the more there is stalemate. But even slow progressors with low initial viral loads can note increases in this viral load in time - that risk is always there. Thus the need to keep monitoring.
We'll keep updating our knowledge on here - for now, I'd say all was going well for you. If more STIs kept lowering your set point further, I'd say it would be a good thing that got even better. If it didn't go lower - I'd still say you've got a fortunate balance now that should keep you well for years to come.
Hope that helps.
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