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Re: Your answer on CD4's that are unusually high and VL's unusually low for someone with HIV
May 20, 2004

In a recent answer, you indicated that it is very rare for someone HIV infected to have a high (>900) CD4 count. I know that averages and medians can be misleading, but can you possibly convey the typical/average CD4 levels and viral loads that you have seen through the years in HIV positive patients in the first, second, third and fourth years after infection and/or diagnosis? I know too well that the CD4's plummet during primary infection and then recover...what do you see in the average/typical patient and where is the CD4 and viral load threshhold for your feeling that someone's immune system is doing a better than average job in handling HIV infection n these early years?

Many thanks.

Response from Dr. Pierone

As you mentioned, it is common to see an initial steep decline in CD4 count with primary HIV infection. This acute decline typically recovers within 6 months and then begins a slow and fitful decline over time. The majority of persons with untreated HIV infection will have CD4 counts over 500 during the first 4 years. A rule of thumb is that the average CD4 count starts at about 1000 and the average decline is about 80 CD4 cells/year. The typical or average viral load might be in the 50,000 range.

So an individual with a viral load of 10,000 (or lower) and a persistently high CD4 count (above 700) in the first 4 years could be considered to be doing a better than average job in handling HIV infection. One of the remarkable aspects of HIV infection is the tremendous human variability in response to this virus. Some people have low viral loads and high CD4 counts and show very slow signs of immune damage over the course of years. Other people appear to be vulnerable with high viral load levels and rapid progression. The timing of antiretroviral therapy depends on which course plays out in an individual deferred treatment for those with slow progression, earlier treatment in the case of for rapid progression.

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