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anomalous CD4 percentage
Jun 4, 2004

Hi:

I'm 54yo, male, asyptomatic and infected less than 2 years. my last 3 T-cell counts (approx 3-4 mo apart) were practically identical in absolute count - about 470 - but the percentage has dropped sharply from 25% to 18%. This seems to be because my CD8's have gone into overdrive from 1000 to 1700. Viral load tending up from 40K to 70K. My CD4/CD8 ratio once holding steady at 0.5 is now suddenly 0.3

What is the significance of these high CD8 counts? If I were your patient would you be recommending I start treatment?

Thanks in advance for your advice. I read the forum regularly and have found it very helpful.

Response from Dr. Pierone

The overall significance of the change in your numbers is not yet clear. It is very difficult to define a trend based on 3 readings. But if the next 2 counts confirm the increased viral load and lowering of the CD4 ratio and percentage then I would be concerned.

But concerned enough to recommend treatment? Not necessarily. I still generally go by the authoritative guidelines (DHHS, IAS-USA, BHIVA, etc) in most matters and typically wait to recommend therapy until the CD4 count is below 350 cells or so. This does not mean that I think it is unreasonable to start sooner. In fact, we are involved in research protocols in which we start therapy straight away for some participants with normal CD4 cells (SMART study).

Outside of this trial, I also have patients that prefer to start therapy at an earlier point than the guidelines call for. I don't argue with them, but facilitate their informed choice. Many people don't realize how much better initial antiretroviral therapy has become recently. Contrast the original regimens like Combivir-Crixivan (8 pills, multiple daily dosing, chock full of side effects) with contemporary regimens like Viread, Epivir, Sustiva (3 pills once daily, well tolerated).

As the medications get better, the pendulum will swing back to earlier treatment. By the way, earlier treatment doesn't have to entail lifelong therapy either. The best long-term strategy for HIV management remains to be determined and will certainly evolve over the coming years. Stay tuned!



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