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Need your help to help (Thanks)
Jan 21, 2010

Afternoon Dr

First and like always, thanks for all your help and support. Since I have been diagnosed HIV+ (more than 2 years ago) I started helping HIV people in my community as much as I can (listening them, supporting them, guide them to the different clinics and doctors that we have in town, to this webpage, etc) been honest there is no much information available in my community (it is scaring been tell that you are HIV+ and find out that there is no info/support for you to use)

Need your help, I have a person detected HIV+ one year ago that refused to test his CD4, VL, etc, last week he finally did and these are his numbers:

VL: 9326, CD4: 405 and CD4%: 17

He show me his labs today, based on him CD4 405 is a really good number and since it is not under 200 it is not a need for him to take any other actions. I suggested him to reach an HIV specialist since his CD4% looks low for me (besides is the right thin to do). He wants to wait as much as he can to see a specialist since he is afraid of discrimination (like all of us I guess). Since I couldnt convince him I made a deal with him, send you this email and he will go with your suggestion.

Favor, can you please explain him the 3 measures (VL, CD4 and CD%) and based on his results what do you recommend?

Thanks Dr you are the best

Response from Dr. Frascino

Hi,

How unfortunate that nearly 30 years into the HIV/AIDS pandemic HIVers are still having to deal with stigma and fears of discrimination!!

Regarding HIV-monitoring tests, see below. You should also suggest your buddy visit this site, as there is a wealth of information here for him.

Regarding ongoing care for HIVers, I recommend he see an HIV specialist physician and have routine follow-up visits every three to four months that include laboratory tests (CD4, CD4%, VL, etc.). A number of baseline tests and vaccinations are also recommended at the time of the initial visits.

As for treatment with antiretrovirals, many current guidelines recommend beginning treatment when CD4 cell counts are in the 350-500 range. I would not wait until CD4 cell counts drop to 200. Again, he can read much more about when to start treatment in the archives of this forum and on related links.

Good luck!

Dr. Bob

CD4 Cell Tests March 21, 2009

What Are CD4 Cells?

CD4 cells are a type of lymphocyte (white blood cell). They are an important part of the immune system. CD4 cells are sometimes called T-cells. There are two main types of CD4 cells. T-4 cells, also called CD4+, are "helper" cells. They lead the attack against infections. T-8 cells (CD8+) are "suppressor" cells that end the immune response. CD8 cells can also be "killer" cells that kill cancer cells and cells infected with a virus. Researchers can tell these cells apart by specific proteins on the cell surface. A T-4 cell is a T-cell with CD4 molecules on its surface. This type of T-cell is also called "CD4 positive," or CD4.

Why Are CD4 Cells Important in HIV?

When HIV infects humans, the cells it infects most often are CD4 cells. The genetic code of the virus becomes part of the cells. When CD4 cells multiply to fight an infection, they also make more copies of HIV. Advertisement

When someone is infected with HIV for a long time, the number of CD4 cells they have (their CD4 cell count) goes down. This is a sign that the immune system is being weakened. The lower the CD4 cell count, the more likely the person will get sick. There are millions of different families of CD4 cells. Each family is designed to fight a specific type of germ. When HIV reduces the number of CD4 cells, some of these families can be totally wiped out. You can lose the ability to fight off the particular germs those families were designed for. If this happens, you might develop an opportunistic infection (see Fact Sheet 500).

What Is a CD4 Test?

A small sample of blood is taken from your finger. The blood is tested to count several types of cells. CD4 cells are not counted directly. Instead, the laboratory makes a calculation based on total white blood cells. The CD4 count is not exact.

What Factors Influence a CD4 Cell Count?

The CD4 cell value can change a lot. Time of day, fatigue, and stress can affect the test results. It's best to have blood drawn at the same time of day for each CD4 cell test, and to use the same laboratory. Infections can have a large impact on CD4 cell counts. When your body fights an infection, the number of white blood cells (lymphocytes) goes up. CD4 counts go up, too. Vaccinations can cause the same effects. It's best to wait a couple of weeks after you recover from an infection or get a vaccination before you get a CD4 test.

How Are the Test Results Reported?

CD4 cell tests are normally reported as the number of cells in a cubic millimeter of blood, or mm3. Normal counts are usually between 500 and 1600. CD4 counts usually drop gradually in people with HIV. However, in some cases they can drop quickly. Because the CD4 cell counts are so variable, some health care providers prefer to look at the CD4 cell percentages. These percentages refer to total lymphocytes. If your test reports CD4% = 34%, that means that 34% of your lymphocytes were CD4 cells. This percentage is more stable than the number of CD4 cells. The normal range is somewhere between 30% and 60%. Different labs use different ranges. There are no guidelines for treatment decisions based on CD4%. However, a CD4% below 14% is a definition of AIDS.

A CD4 count below 200 indicates serious immune damage. It is a sign of AIDS in people with HIV infection. A recent study showed that the CD4% is a better predictor of HIV disease progression than the CD4 count. However, the CD4 count is used to decide when to start treatment.

What Do the Numbers Mean?

The CD4 cell count is a key measure of the health of the immune system. The lower the count, the greater damage HIV has done. Anyone who has less than 200 CD4 cells, or a CD4 percentage less than 14%, is considered to have AIDS according to the US Centers for Disease Control. CD4 counts are used together with the viral load to estimate how long someone will stay healthy. See Fact Sheet 125 for more information on the viral load test.

CD4 counts are also used to indicate when to start certain types of drug therapy:

When to start antiretroviral therapy (ART): When the CD4 count goes below 350, most health care providers begin ART (see Fact Sheet 403). Some health care providers use the CD4% going below 15% as a sign to start aggressive antiviral therapy, even if the CD4 count is high. More conservative doctors might wait until the CD4 count drops to near 200 before starting treatment. A recent study found that starting treatment with a CD4% below 5% was strongly linked to a poor outcome.

When to start drugs to prevent opportunistic infections: Most health care providers prescribe drugs to prevent opportunistic infections at the following CD4 levels:

Less than 200: pneumocystis pneumonia (PCP; see Fact Sheet 515) Less than 100: toxoplasmosis (see Fact Sheet 517) and cryptococcosis (see Fact Sheet 503) Less than 50: mycobacterium avium complex (MAC; see Fact Sheet 514) Monitoring treatment success: With successful ART, CD4 counts rise. Sometimes they rise quickly. Other times they can go up slowly. If the CD4 count is below when ART is started, CD4 counts might not recover to normal levels. Also, if CD4 counts fall while you're taking ART, you might have to change your medications.

"Non-AIDS" Illness and Death

Now that people with AIDS are living are longer, there is more research on other causes of illness and death. These "non-AIDS" causes of death include liver disease, non-AIDS cancers, and heart disease. Overall, these deaths are decreasing. However, research shows a clear link between lower CD4 counts and the risk of death.

The Bottom Line

Because they are such an important indicator of the strength of the immune system, official treatment guidelines in the US suggest that CD4 counts be monitored every 3 to 4 months. See Fact Sheet 404 for more information on the treatment guidelines.

The Viral Load Test

Viral load tests provide an estimate of how much HIV is circulating in your blood. Generally speaking, your viral load is not considered as critical as your CD4 count in determining the health of your immune system. However, once you begin HIV treatment, it is a good measure of how well your HIV medications are working.

A viral load test measures the amount of HIV in a small amount (milliliter, or mL) of your blood. Current viral load tests can detect as few as 50 copies of HIV per milliliter of blood. When your viral load test indicates that you have fewer than 50 copies/mL of HIV, your health care provider will tell you that your viral load is "below the limit of detection," or "undetectable."

This does not mean that you no longer have HIV in your body. Even someone who has an "undetectable" viral load can transmit HIV. However, an "undetectable" viral load means that your medications are doing an excellent job of keeping HIV in check.

To view frequently asked questions about viral loads and the viral load test, click here.

To read more about viral load, check out our collection of articles.

HIV Drug Resistance Testing

Besides a CD4 count and viral load test, your HIV specialist will look at your overall health with a general blood count test. You may also be given an HIV drug resistance test. A resistance test will tell you if your HIV has already become resistant to any HIV medications.

How could this happen? The person you got HIV from may have been on HIV treatment and his or her virus may have become resistant to one or more HIV medications. Transmitted along with HIV was resistance to certain drugs. So before you take treatment, you'll want to be sure your HIV is not resistant to any drugs.

To view frequently asked questions about HIV drug resistance and the drug resistance test, click here.

To read more about HIV drug resistance, check out our collection of articles.



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