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Absolute CD4 vs. Percentage CD4 as Marker for Treatment
Oct 28, 2002

Dr. Wohl,

I have really enjoyed how clear and concise your answers are, and how sensitively and respectfully you present them. Your coining of the term "lemonAIDS" gave me the chuckle I've needed all day.

Here's my concern. I tested positive Jan. 2000 at cd4=620ish and VL=136,000 - and I started Combivir/Sustiva immediately. I remained 99.9 compliant and tolerant of this regimen at VL<50 and cd4=500-620ish until I Dx'd with primary CMV infection (primary according to Dr. Eric Daar at Cedars Sinai) in July of 2001. Because it hit my liver, I was taken off antiretroviral Tx and remain off Tx since we learned at that time that starting medications at 600 cd4 did not produce significantly better treatment outcomes than for those who waited until about 350 cd4. Well, now my cd4 is below that marker at 198 and VL>75,000, but my percentage is 24.0 - cd4 down from 420 three months ago. My doctor (another doctor) and I feel we should wait two months for another test to see trends and to account for any variations in testing.

Here are my questions: What is your opinion about risks/danger in waiting 2 months to test again before treatment? Should I be taking any prophylactic treatment (Bactrim, etc.) for OI's? Do these latest results mean I now have AIDS? Given this history, what would be your best estimation of the length of time I could benefit from meds we now have available?

Many people in my life are up in arms because I have not demanded that I start Tx right now, but I just want to make a well-informed decision before putting my liver back to work on antiretrovirals (by the way, genotype tests indicate I'm still sensitive to Combivir/Sustiva).

Thanks for your time!!!

Response from Dr. Wohl

Hi-

Thanks for your comments. If I understand you correctly, your CD4 cell count has dropped from 420 to 198 over 3 months but your CD4% has remained about the same. If so, then I agree with your clinician and would not initiate HIV therapy just yet. The value has to placed within the context of all those that preceded it. If your absolute and % CD4 counts have been slowly dropping over the past year or two, this drop in absolute CD4 seems to stick out, and therefore should be verified.

You do not have to wait 2 months though. I would check you again in 2-4 weeks. I would also make sure there is nothing you are taking that could interfere with your body's ability to make white blood cells (WBC). I'd hold off on Bactrim as your risk of PCP is low and this is a medication that can impede WBC production.

I suspect you were just having a bad WBC day and that your counts will be more comforting on repeat testing. You don't have AIDS. DW

(PS. Remind your clinician to order the regular rather than ultrasensitive viral load test while you are off of therapy as its upper limit is 750,000 as opposed to 75,000. Just a pet peeve.)



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