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What about the "memory" of cells
Aug 27, 2007

Dear Dr. Young,

Dutch guy here again. I have a question about the "memory" of cd 4 cells and early treatment with medication.

Please correct me if I'm wrong. I've learned that during life the cd4 cells "fill" their "memory" with diseases they have battled in the past. The HI Virus kills these cells (and erases some memory I guess)

Can I conclude from this that when a patient coming from 400 cd4 cells and now on medication reaches 600 cd4 cells is in better shape then a patient coming from 200 cells and reaching 600 cells?

And if so, is this one of the reasons why starting earlier with medication is recommended?

And if there's "some memory loss". Is there a chance that diseases I had in my early youth can reoccur (like chicken pox and measles).

Last thing: the medication is not really candy. I often hear things like: lifelong chemo therapy or lifelong toxicity when people are discussing medication. Is there any forecast or expectation about the long term side effects (comorbidity) which justifies starting medication at higher cd4 counts.

Of course I don't expect 100.00% water tight guarantees. It's more that I want to make a well informed decision when it comes to using medication. In other words: what's the right balance. I personally would mind starting early if the advantages outweigh long term risks.

Kind regards, Dutch guy

Response from Dr. Young

DG, great to hear from you again.

A very nice summary of the debates in HIV medicine-- there is data that the CD4 cells that come "back" so-to-speak, are actually quite healthy. Nevertheless, there is competing data that there is some loss of memory, particularly when it comes to HIV responses. Hence, I'd tend to agree with our statment about the two different patients with CD4s of 600- meaning that the one with the lower CD4 nadir being at higher risk than the one with the higher (400) nadir.

There is quite a lot in the literature about the effect of CD4 nadir on the disease response- from increased risk of side effects, drug resistance and safety of treatment interruption. All of these appear to point to greater risk among persons with lower nadir, even after immune reconstitution.

You're also right that HIV medications are not candy. (Though too much candy can be bad for you too.) Exactly to your previous question are data presented from my collaborator, Kenneth Lichtenstein from the HOPS cohort- his recent analysis shows very strongly that the risk of toxicity is less among persons with higher CD4s.

So, yes, there is a balance of important issues. But as treatments get better tolerated and the apparent risks of waiting to start grow, more and more of my patients are starting sooner rather than later. As summed up by Dr. Joel Gallant's TheBody podcast, the trend now is to ask the question, "when wouldn't you start treatment?"

Hope this helps. BY


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