Dear Doc, Recently I was diagnosed HIV positive. I have been married for 4 years and was planning to start a family as a result my wife and I both got a routine blood check done. My wife was tested negative. My initial test before any medications showed a viral load of 3500 and CD4 of 202. However 2 weeks after medication (combovir and abacavir), test showed that the viral load is undetectable but CD4 dropped further to 182. My worry is in spite of the vl having dropped to undetectable why has my CD4 decreased further down? I have been healthy so far and never had illness of any kind for more than 25 years. Can you please answer my following questions: 1. In spite of the vl having dropped to undetectable after medication why has my CD4 decreased further down? 2. How long do you think I have been infected before I was diagnosed? 3. What could be the reason for a low CD4 and low vl before starting the medication? 4. I would like to know what "long term non progression" means. Thank You

Will do.

In reverse order - long term nonprogressor is a phrase used to describe a few percent of those who have HIV infection but have very low viral loads AND no evidence of any damage to the immune system despite the presence of HIV. And no illnesses that we can find as a result of HIV infection for over a decade. And it is this group that has taught us about the capacity of the immune system to potentially control HIV, and encourages us to find ways to help others do the same. Since it appears that we can tolerate relatively low levels of HIV replication for quite a while.

However, some have the situation you describe - despite a low viral load, there is also a low CD4 count. It is less clear how this is the case but there are a few possibilities. One is that your own CD4 cell count was on the low end when you were negative - while normal is about 800, some are below 500 and don't have HIV infection. So perhaps yours was 400 - enough to be well, and then with the stress of HIV - it has dropped further. While we can guess - there is no way to know for sure how long you have had this - as the starting point, and the rate of cd4 drop can vary too much to be precise.

Another possibility of how this happens is that there are a few strains of HIV that are not readily measured on some of the standard viral load tests - although now that you are on meds it will be harder to see if this would explain your result as all strains do respond to these meds - so your virus should be suppressed by the meds you are on - and it is encouraging just how quickly you dropped down.

Finally -we differ in how well our immune system can keep up with cell production despite HIV. So - since you don't mention your age - the older we are the less our body can create new cells. There are other differences despite even a younger age to suggest why some will have more damage done at lower viral load levels - just a decreased ability to make new cells for reasons that we are still learning about.

But it is too soon to say that your counts are not responding to viral suppression. You need to know that there is tremendous variation in these counts and how they are measured - a crude figure to capture the variation is about 20% differences in the result could be seen just from normal variations. So for example with your count of about 200 before meds - if on that day the blood was taken it was put in ten different tubes and sent to the lab you would be expected to see a variation to perhaps as low as 160. So far, I would only say that you have had a delayed response to meds - not a drop. It is pretty unusual to actually drop. So it is more likely that with continued monitoring, you should see increases over time.

One possible reason, however, for this apparent drop that would lead to a change is your response to the combo you are on. There are some who are sensitive to the medication AZT - it is one of the two antivirals in the Combivir pill. And some will have a drop in their white cell count so that you might see this drop in your counts persist. If so - and if your CD4 percent were actually rising while the cd4 count is not - you might consider an alternative to the AZT. You can take a look at this with your standard lab reports.

But hang in - odds are very good you too will have a higher cd4 count over time.

Hope that helps.

CC