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88 CD4 with med
Jan 1, 2009

My sister has been on meds (combivir and stocrin) for three years now. She started when her CD4 was 10. A week later it went up to 35 and then to 5o and for most of the last two years it has been between 87 and 94. This week she was tested and the CD4 is 88 while the percentage is 11 having been 18 percent a year ago. Dear Dr. Benjamin what do you make of these? Do you think there is drug resistance? Here in our country there is no viral load test. If the virus has gone drug resistant, which regimen do you think is next in line for her?

Response from Dr. Young

Thanks for your post.

I share your concern about your sister's lab results. We would typically expect to see CD4 percentages (and absolute count) rise pretty continuously over the first year of treatment.

While I wouldn't place too much emphasis on any single test (because of the considerable variability in values), a decline of CD4 percentage and count such as she has had raises the possibility of treatment failure and drug resistance (assuming that she has been adherent to her medications).

In our country, our next step would be to get viral load and HIV resistance testing. The later would be used to design a next treatment regimen. Without these, clinicians are forced to use alternative measures or clinical assessment to decide if treatments are working or not. It would be useful to know if she has new symptoms or weight loss- these findings would often corroborate the conclusion of treatment resistance.

Before deciding on what to use next, it is critically important to assess why treatment failure occurred, if at all possible. Clearly adherence has to be considered, lack of continuous supply of medication can be a cause of failure for some patients. Having active HIV complications can sometimes cause spurious lab results without true drug resistance.

A next treatment regimens will undoubtedly include a ritonavir-boosted protease inhibitor. Given that you're probably living in a resource-limited setting (because of the absence of viral load tests), the most commonly used regimens for second-line treatments usually involve lopinavir/ritonavir (Kaletra) with two other HIV medications. These can be successful treatments, but care for adherence and monitoring are even greater considerations for any second- or subsequent treatment regimen.

So, I hope that this discussion is helpful; please write back to me at any time.

I wish you and your sister a healthy new year.


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