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high vl / highcd4

Jul 19, 2002

I see where most people (chronically infected) have high vls with low cd4s or low cd4s but also relatively low vls(<20,000).So what is your opinion on someone who has high cd4's but also a high vl(>100,000) is watching an option or would you insist on treating.I'm referred to cd4's over 800.Thank you

Response from Dr. Wohl

The answer to the question of when is it okay to just follow CD4 cell counts and viral loads without treating with HIV medications changes depending who you ask and when. Just a few short years ago persons living with HIV were being prescribed triple antiretroviral therapies with CD4 cell counts double what we now consider the threshold for initiating treatment. With more information on side effects and studies of persons who started HIV therapy at different CD4 cell counts, clinicians are now tending to prescribe treatment at relatively lower CD4 levels (i.e. around 300-350).

As you mention, its not just the CD4 cell count but the viral load that helps determine when therapy should begin. The higher the viral load the quicker the CD4 cells tend to drop. Therefore, some consider starting therapy when the viral load is very high (several hundred thousand and more) regardless of CD4 cell counts. Most, however, would wait and watch what happens to the CD4 cell counts over time. In the case of someone with a CD4 cell count of 800 and a viral load of 100,000+ and who is NOT symptomatic from HIV (I mean no thrush, night sweats, fevers, wasting etc), I would recommend waiting and following the counts every 3 to 4 months watching for a significant drop or for symptoms that would prompt me to consider begining HIV treatment. But, watch that pendulum, it just might swing back toward 'hit hard hit early' and the answer would change again- DW

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