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Low CD4
May 23, 2012

I am 45 year old woman from India.Taking Duovir(twice daily) and Efavir 600 (once daily)since May 2008.Blood parameters at that time were :Viral Load 155618 copy/mL, Abs CD4-62,%CD3+/CD4+(T-Helper cells)-7.9%,Hb-11.5,RBC-4,26,WBC-3.83. Now physically I feel much better with no infections,fatigue or any other symptoms of disease but CD4,RBC and WBC are still low. New readings in April 2012 are : viral load 45 copy/mL,Abs CD4-164,%CD3+/CD4+(T-Helper cells)- 17.2%,Hb-12.3,RBC-2.90,WBC-3.5. I read somewhere that AZT supresses RBC and and also causes low CD4 and TDF/FTC/EFV or TDF/3TC/EFV are better combination from point of view of long term toxicity, lipotrophy and RBC/CD4.Also if resistance is developed with TDF ,AZT may still be used as second line regime but reverse is not possible. My doctor is experienced Medical College Prof. He agrees with effectiveness of TDF but says that as I am physically fit and virus is under control there is no justification for changing the medicine at present. He recommends change only if signs of failure or any side effect appear. Please advice whether increase in CD4 is adequate,whether to continue with present regime or switch over to TDF/3TC/EFV.

Response from Dr. Young

Hi and thank you for posting from India.

First, it seems like you're doing pretty well on your current treatment. Your CD4 count has improved considerably from when you started (from 62 to 164) and seems like you're not experiencing any side effects of your medications. Indeed, worldwide, the regimen that you're taking is probably the most commonly prescribed.

AZT can cause bone marrow suppression and anemia in some people, and compared with other medications causes a slightly lower CD4 count (about 30 cells in one comparative study). Such difference in CD4 cell performance, in my opinion, isn't enough to alone justify changing a successful regimen.

Switching treatments is recommended to simplify treatment (decreased pill number or dosing frequency) or to decrease side effects. A switch from AZT+3TC to TDF+3TC would decrease your dosing to once daily. Since you don't have any side effects of your AZT (or at least don't think that you do), then there might not be any difference- though many who have switched have reported feeling somewhat better. It should be said that if you have significant problems (or risks of) kidney or bone disease, then I'd avoid the use of tenofovir.

The proposed regimen is a well recommended regimen- indeed, most commonly prescribed here in the US for first-line treatment; you're correct that should resistance occur to the TDF-based regimen, that AZT often retains activity.

In sum, there's no right or wrong approach. If going to once daily is attractive and could improve your adherence to medications, then a switch is entirely reasonable.

I hope that's helpful, BY



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