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To start or not, that is the question
Sep 20, 2003

Thanks for your great efforts on this site.

My viral load has always been relatively low but so have my CD4 cells. I've been tested three times; a) VL 3,000 cd4 281 b) VL 1,500 cd4 325 c) VL 17,000 cd4 301. Other than a mild persistent sore throat I've been in very good health. Shrink says it my be a side effect of Prozac.

I have an opportunity to enroll in a research study with two arms 1)tenofovir, emtricitabine and efavirenz all once daily or 2) combivir twice daily and efavirenz once daily.

I'm not really crazy on the idea of starting meds at all but will absolutely do what I must to maintain my health. I know my adherence will be l00 percent (sometimes compulsivity has it's benefits).

Two questions; Do I need to start now at all? Are either of these drug combos a "best choice" in your opinion? Ok, three questions. I have been positive for anywhere from 6 to 18 mos at most. Why are my cd4 cells so low and is it possible they will (at least temporarily) rebound to higher levels. A fellow HIVer said that often within the first year after acute infection the cd4 cells do rebound before gradually declining. True? Looking for some good news somewhere.

Thanks so much for your time.

Response from Dr. Pierone

In your situation, the risk of developing an AIDS-related complication is low over the next 3 years is probably less than 5%. The time to start treatment is probably when CD4 cells are in the 200 to 350 range. But with a low viral load like yours, there is less urgency. So the answer to the first question is no, you do not need to start now, but starting treatment at this point would certainly be a reasonable thing to do.

If you do decide to start on treatment, the clinical trial that you are considering is a good one. It compares the promising newcomer regimen of tenofovir (Viread), emtricitabine (FTC, Emtriva), and efavirenz (Sustiva) to what is currently the most popular initial regimen in the U.S. Combivir and Sustiva. Both are very good choices, this study may tell if one is marginally better than the other.

Generally, the combination of fairly low CD4 cells with a low viral load suggests longer term infection with HIV with very slow progression. But it sounds like your situation is different and it's hard to know why. It is true that after HIV acute infection CD4 cells often plummet and then slowly recover, but usually we see this is the context of high viral load of acute infection. If your CD4/CD8 ratio was on the higher side (above 0.5) that would also suggest better immuonologic function and this can and should be followed over time. The normal ratio is about 1.2 and declines gradually in concert with decreases in CD4 cells. Typically, someone with 200 CD4 cells has a CD4/CD8 ratio of about 0.2.

Hope this helps and good luck!



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