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Initiation of Therapy
Jan 13, 2002

DEAR DR.COHEN, GOOD DAY TO YOU! WITH FIRST BLOOD WORKS RESULT,MY CD4 570 AND MY VL510 NO MEDS YET. SINCE THERAPY INITIATION STARTS WHEN YOUR CD4>350/VL >35-55,000 1) WOULD I WAIT FOR MONTHS OR YEARS TO START A THERAPY. THEY SAID THAT 50/70 OF CD4 DECREASES PER YEAR,

2)WOULD THAT ALSO APPLY TO THOSE PERSON TAKING ANTIVIRAL MEDS OR ONLY TO THOSE POSITIVES THAT ARE NOT TAKING ANY MEDS.

3)BASED OF MY CD4 OF 570, AND LESS 70 OF EACH PER YEAR, SO I WOULD WAIT FOR 3 YEARS TO START MY THERAPY SINCE IN 3 YEARS MY CD4 WILL GO DOWN TO 350.

4)THAT MEANS I HAVE LIKE 8 YEARS TO LIVE IF I DON'T TAKE ANY MEDS? WITH MY CD4570? WHY ARE SOME PEOPLE HAVE HIGHER CD4? I GUESS MINE IS AT THE LOWER LEVEL OF A NORMAL RATE. SHOULD I BE ALARMED WITH MY LOW CD4 SINCE I AM (FEMALE 30) ONLY INFECTED JULY 2000, HOW COME THERE IS A BIG DROP IN MY CD4 SINCE MY VL IS ONLY 510?

5)HOW MUCH DO YOU THINK MY VIRAL LOAD OF 510 WILL INCREASE IN 3 MONTHS.

6) HOW WOULD MY VL510 AFFECT MY PROGRESSION. WILL I PROGRESS FAST OR SLOW.

I AM VERY SORRY FOR I HAVE LOTS OF QUESTIONS. I HOPE YOU WILL ANSWER IT IN ORDER.

THANK YOU VERY MUCH

KAREN

Response from Dr. Cohen

Since you asked to have your concerns addressed in order that you pose them - here we go:

1) WOULD I WAIT FOR MONTHS OR YEARS TO START A THERAPY. THEY SAID THAT 50/70 OF CD4 DECREASES PER YEAR.

The timing of when to start is one of those things we can discuss and discuss... and there are reasons to focus on this key issue. Since it is a big deal when you finally do decide to start meds to control HIV. But, you ask about the rate of loss of Cd4 cells - and with your low viral load, it is unlikely you will lose Cd4 cells at the rate you mention - the higher the viral load the faster these cells are lost. And the lower, the slower. And your viral load is quite low. If you really mean just 510 copies, this level of virus growth is associated with long periods of CD4 count stability - meaning no need for treatment for years and years.... assuming you respond in a typical way - with a stable viral load in time, and stable counts as well. And while you could start treatment, it would appear safe to postpone as well.

2)WOULD THAT ALSO APPLY TO THOSE PERSON TAKING ANTIVIRAL MEDS OR ONLY TO THOSE POSITIVES THAT ARE NOT TAKING ANY MEDS.

The rate of decline you ask about is for those NOT on meds - once on effective meds - the counts tend to increase again. So if I understand your question - this rate of CD4 decline is for those off treatment, and with a viral load closer to 50 thousand.

3)BASED OF MY CD4 OF 570, AND LOSS of 70 OF EACH PER YEAR, SO I WOULD WAIT FOR 3 YEARS TO START MY THERAPY SINCE IN 3 YEARS MY CD4 WILL GO DOWN TO 350.

As mentioned - this loss of cells will likely be much slower for you. Unless your viral load increases, your counts are likely to be pretty stable for the next few years. So you may not want to start treatment in the next three years if that is what happens...

4)THAT MEANS I HAVE LIKE 8 YEARS TO LIVE IF I DON'T TAKE ANY MEDS? WITH MY CD4570?

Well - if you never started treatment you likely would live longer than 8 years. Again, a viral load near 500 is someone who may be in a category that we have called long term slow progressor - a category that includes some who have never been on treatment and years later are well even without treatment.

WHY ARE SOME PEOPLE HAVE HIGHER CD4? I GUESS MINE IS AT THE LOWER LEVEL OF A NORMAL RATE. SHOULD I BE ALARMED WITH MY LOW CD4 SINCE I AM (FEMALE 30) ONLY INFECTED JULY 2000, HOW COME THERE IS A BIG DROP IN MY CD4 SINCE MY VL IS ONLY 510?

We don't know what your counts were before infection - it is possible that a count of 510 is what you had even before infection - and if it was higher then, it is still in a range that is protecting you from all infections. So this is a safe count to have.

5)HOW MUCH DO YOU THINK MY VIRAL LOAD OF 510 WILL INCREASE IN 3 MONTHS.

In general the viral load is stable. Over years. In the next few months it should be the same. But since we cannot always predict the future for everyone - we measure it every few months - but it is likely your count will be stable for months and months...

6) HOW WOULD MY VL510 AFFECT MY PROGRESSION. WILL I PROGRESS FAST OR SLOW.

Slow slow slow as I've said. You are one of the luckier ones. With a count that might leave you alone - without meds - without treatment issues - and with a stable Cd4 count that protects you from HIV related illness...

GOOD LUCK!!



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