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Life expectancy and
Nov 22, 2008

Doctor Sherer,

Life expectancy:

My 20th birthday is December 1. I am aware of the exact sexual interaction when I contracted the virus, which was in June 2008. I was tested randomly in July 2008 and was found to be positive. After being introduced to an inexperienced doctor, I now am being treated by a seasoned specialist. However, when the full set of tests were finally taken in September, my CD4 was 198; I began treatment a month and a half later at 129. I have AIDS. Is starting treatment in November after contracting HIV in June considered a late start? Does the fact that this is now an AIDS-defining illness greatly reduce the 69 year life expectancy that is being quoted?

Functional cure:

There have been articles that state if the CD4 count is made high enough through early ART treatment and there is an undetectable viral load, a "functional cure" has been obtained--a healthy, long life without major HIV-related illness or health issues. It also has been said that if the described conditions take place, the body can fight the virus on its own. That said, if doctors boosted a HIV+ patient's immune levels to higher than normal after those conditions have been acheived, isn't it a possibility the body will eradicate the remaining virus on it's own? I know there are many "reservoirs" of the virus that can be found, but wouldn't the natural immune system be able to combat them?

Thank you,

G.M.

Response from Dr. Sherer

I'll start with the second question: No, even when treatment returns the CD4 cell count to normal or near-normal levels, the body's natural defenses are not able to eradicate or adequately control the virus. Even in a person who has excellent control of the virus and near-normal CD4 cell counts, if ART is stopped, viral replication will recur, the CD4 cell count will gradually fall over time, and that individual would again be at risk for HIV-related infections. And, as we have recently learned, that individual with low CD4 cells would also be at an increased risk of other non-HIV causes of morbidity and mortality such as heart disease, chronic liver disease, kidney disease, and non-HIV related cancers.

Regarding the first question, there are several factors that contribute to the risk of HIV disease progression. One important one is whether the individual has developed an AIDS-related opportunistic infection (OI) such as pneumocystis pneumonia. People who have never developed this type of infection had a longer life expectancy (69 years) in the MACS study of gay men, compared to those who DID have such an infection, whose life expectancy on ART was significantly lower (49 years). This dramatically explains why doctors and public health officials are urging anyone at risk of HIV to be tested and to start treatment BEFORE they ever become sick.

You asked a different question, i.e. are you 'late' in starting treatment 5 months after you were diagnosed with HIV. Since the national average is 6 months, you are pretty normal. And since you didn't have all of the right information and the right doctor until September, your delay was more like 2 months. It is very important to understand that, even when prompt ART is indicated, it is not an emergency to start ART immediately. It is most important to get it right, i.e. to start properly, to be sure that you and your doctor have chosen the best regimen for you, that you know what is supposed to happen and what might go wrong (e.g., with side effects or other unexpected events), and that you have a way to consult with your doctor or pharmacist while you start, in order to ensure that you take the medications exactly as prescribed.

It is clear that you are better off starting treatment as soon as you meet the criteria in current treatment guidelines, which advise starting ART if your CD4 cell count is below 350 cells/ml. Since you have not had an OI, you have an excellent chance of reaching 69 years of life. You can maximize your chances by keeping all of your doctor appointments and doing everything possible to take your medications as prescribed. To be clear, then: Even though the definition of AIDS was expanded to include people with a CD4 cell <200 cells/ml, there is still a large amount of data, including the MACS study on life expectancy, that shows a worse prognosis for patients who have had an AIDS-defining opportunistic infection or tumor, but not necessarily for those individuals with no such infections and a CD4 cell count below 200 cells/ml.

I suggest that you talk to your doctor about your concerns and this response.


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