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Possibly starting therapy this year with very low baseline VL

Feb 9, 2003

Hi Dr. Wohl, I found out I was positive in December of 2001. Since then I've been having labs done every four months. My cd4's have been between 540 to 735 with my VL being between undetectable to about 1500 copies. My last reading 3 weeks ago was VL of 1500 (PCR) and a cd4 of 420 (20). My doctor said my absolute count was a "little bit low" and she wants a repeat test in three months. Reviewing my past labs I noted there has been some disease progression. My first lab 13 months ago said I had a total cd4 of 24, now it's at 20. I suspect that if the trend continues, she will probably recommend therapy within the year to year and a half. She did comment though that being therapy naive and with my slower disease progression that I was in a "real good place" as far as HIV goes. What do you think? Based on my very low VL numbers, do you think it's probable that If I am successful with therapy for a year or two, just long enough to increase my cd4's to very high numbers, that I can stop therapy for a couple of years or longer and just follow my labs? When I decide to start therapy again can I continue with the same regiman or could there be a resistance issue? Also, do you think disease progression might even be slower the second time around therefore keeping me off drugs even longer? Taking antivirals sounds more appealing if I know I may be able to have breaks like 2 years on, 4 years off. Thanks Doc!

Response from Dr. Wohl


It does sound like you have had a very slow decline in your CD4 cell count over the last year or so. However, the drop in your counts has been pretty small over that period of time. This, of course, is because you have a naturally low viral load.

I agree with your doctor that continuing to watch your numbers makes sense. I suspect that the CD4 cell counts will fluctuate a bit. With time, one would expect your CD4 cell count to drop to a level where therapy becomes increasingly more attractive but I think you have years to go before you get there.

Make certain there are no other factors that can be contributing to a decline in your immune system such as excessive alcohol, illict drugs, stress, etc.

When the time does come for you to start therapy we may know much more about so called 'pulse therapy' in which people start treatment, reach a CD4 goal, stop therapy and then restart if and when the CD4 returns to a certain level. This seems like a reasonable approach but there are really few supportive data at this point. Most likely, re-starting the same regimen should not be a problem.

Your doctor is correct, you are doing well on paper. If this matches with how you are feeling, I would watch and wait. DW

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