I have been positive for three years now without meds. My CD4 & viral load numbers conitnue to zig zag up and down to a manageable number not requiring meds, until now. My previous numbers, 60 days ago, were 374/29%/376,000 (CD4,CD4%,VL). I just received new numbers now 258/29%/207,000. If my percentage of good CD4s continue to stay the same yet my nummber of CD4s drop, are meds really neccessary? My CD4s have always fluctuated but this is now the lowest CD4 count of my history. My viral load has fluctuated as well but continue to go up then down every time I have blood work done. I have been trying to avoid meds till the last possible moment without causing my body any potential damage. I am very healthy, in great shape, 48y/o and take care of myself. My biggest issue and question is, other than my CD4 count dropping to lowest number yet, I continue to suffer from horrible insomnia and fatigue and am curious if that is caused by the lower CD4 count AND can my lack of sleep be affecting my CD4 count dropping? Much thanks for your input as well as this website!!

Hi,

When to begin combination antiretroviral therapy is a personal decision. Current guidelines recommend beginning treatment when the absolute CD4 count falls into the 350 range. Your counts have been in that range for a while now. Personally I would recommend you consider beginning treatment. There are discussions underway to revise the guidelines to suggest beginning treatment at CD4 counts of 500. I'll reprint some information below from the archives that discusses when to begin treatment.

Certainly your fatigue might be related to your "horrible insomnia" if you are not getting adequate sleep and rest. Talk to your HIV specialist. He should be able to help with this common problem. I do not believe your insomnia is affecting your CD4 count, but it can certainly affect your level of fatigue and quality of life.

Good luck.

Dr. Bob

Should meds be NOW considered? (WHEN TO BEGIN TREATMENT) Dec 26, 2008

Hello Dr. Bob.. Happy Holidays.. and may your coming year be as bright as a shining star.. I recently did my labs on received my results..CD4..453 and viral load 44,000. I have some minor discomfort such as swollen lymph nodes in the groin area and infrequent joint pains in elbow and knees. Do u recommend and consider the start of ARV treatment? Please give me your feedback because I am getting worried whether my immune system is rapidly degenerating.

Response from Dr. Frascino

Hello,

The optimal time to begin antiretroviral therapy remains a hotly debated topic as we learn more about HIV pathogenesis and natural history and develop new, more potent, less toxic medications. I'll try to give you an update on where things stand at the moment, but I would strongly suggest you discuss your situation with your HIV physician specialist, as there are many variables that must be taken into consideration for each individual situation. There is no one right answer for everyone. When it comes to beginning antiretroviral therapy it's a case of "one size fits one!"

A new study presented at the recent AIDS meetings in Washington, D.C. suggested HIV-positive folks should begin antiretroviral therapy sooner than the guidelines currently recommend (CD4 count of 350). The large study found that delaying the start of treatment until the CD4 count falls to 350 nearly doubles the risk of death during the next few years when compared to the risk of death in patients who began treatment earlier (CD4 count under 500). The survival benefit, however, must be weighed against the chances of drug toxicities and side effects. There is also the risk that poor regimen adherence could breed a drug-resistant strain of virus. There are, however, now three recent studies all showing that HIV-positive folks who begin antiretrovirals while CD4 counts are above 350 have a better chance of their counts returning to the normal range (600-1,200) than those who delay treatment until the CD4 count falls below 350.

Personally, as an immunologist, I strongly recommend early intervention with antiretrovirals if the person is ready, willing and motivated to begin taking the medications.

I should also mention there are situations in which we currently start antiretroviral therapy immediately despite CD4 cell counts. These conditions include patients with concurrent hepatitis and certain types of kidney disease and those who are pregnant.

Ultimately, I'm confident there will come a day when any HIV positive patient diagnosed will be advised to begin antiretroviral therapy as soon as they are diagnosed. This year we've seen treatment guidelines for beginning antiretrovirals increase from a CD4 count of 200 to 350. I think it's likely that this trend will continue with a formal recommendation to consider treatment at a CD4 count of 500 in the near future. Stay tuned to The Body. We'll keep you posted as the guidelines are revised. My personal recommendation is to begin antiretroviral therapy as early as possible in most situations, being fully cognizant that there are risks involved and that our scientific knowledge is still incomplete.

Hope that helps.

Dr. Bob