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Questioning My Doctors Treatment
May 21, 2012

I am 45 years old, I tested positive 4 years ago. My initial cd4 was 98 with a viral load of 1900. (Never would have had a clue I was positive if I hadn't been tested) Before I started meds, my viral load dropped even further, while the cd4 slightly rose. 4 Years later, I am still doing fine overall, Since starting my meds (Norvir, Truvada, Prezista) my viral load has been undetectable, but my cd4 has still remained low. Except for the side effects from the meds, mostly diarrhea and tiredness, I have been doing ok. I presented with basically no medical records, (my old doctor died and the hospital destroyed all the old records) So when I tested positive, I was starting from scratch. After two years, I switched from the local aids clinic to a primary care doctor and a infectious disease specialist. The first two years, I didn't feel I received even a full exam and thought since the clinic was overwhelmed I would get better treament in the private sector. After two more years, my primary care doctor I don't feel has given me the full rundown, especially for someone middle aged with HIV. What should a physical exam include? My doctors do the basic, temp, blood pressure, weight, but only after questioning my doctor did he do a prostate exam. I have never been in a gown at the doctors office, so other than visually looking me over and lab tests never really had a full "tap and thump" checkup. My current cd4 is 230, vl undectable. (This is down from a cd4 of 400 about a year ago) I want to get my cd4 up but my doctor (specialist) wants to wait until my cd4 drops below 200 to change my meds. Is it time to find a new doctor?

Response from Dr. McGowan

Thanks for your questions.

The pattern of CD4 change is not unusual especially since A) you had started treatment at a low number and B) you are "middle aged". Both of these can be associated with a less robust CD4 recovery. So far there is no magic bullet that can correct that. Some treatmenst, such as those with a protease inhibitor (like your combo) or an Integrase Inhibitor have shown better CD4 recovery than others, but the differences are small and there is really no evidence that switching from one type of treatment (especially when you are already on a Protease Inhibitor) to a different treatment would help. If the trend is continuing downward (not just a single fluctuation) then a work-up for some underlying process...inflammation/infection, etc may be needed.

As far as the examination, you may need to see a General Practitioner or Family Practice doc for the routine Health Maintenance and screening. While many HIV docs will do the whole thing some "specialists" and Infectious Diseases docs may want to focus more on just the HIV care. Especially when your HIV is well controlled, other issues such as blood pressure, sugar, cholesterol, prostate and colon cancer screening may take up more focus than the HIV.

Joe



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