200 drop in just 6 months

Question

Dr. McGowan, You wrote me before after I raised a question regarding a 200 points drop in CD4 count in just 6 months period (from stable 485 to 325 to 285, with VL slowly rising 15K to 25K to 33K, and % remaining stable the whole time 21-22%). You agreed with me that the reason for the drastic drop might be an acute infection I was having at the time of Syphilis. I decided to wait one month after completion my set of antibiotics shots, and get my numbers tested again before deciding on starting treatment. Now the results are in, and while my numbers didn't go all the way up to 485, they did climb to 305 (10% improvement from 285) and VL came down to 29K (10% improvement from 33K). My % is the only result that actually decrease 1 point going down to 20%. I know thta CD4 numbers may change on a daily basis and even during the day, but isn't a 10% improvement in just one month a sign I need to wait longer and see how much will my numbers will improve by themselves without starting the unreverseable step of medications?? Thank's for any thought on the matter..

Answer

Thanks for the follow up. The pattern of dip and recovery with an acute infection is to be expected. Usually a month is enough time to get back on track. The trend, as you point out, will be one of a steady decline in CD4 count and % over time (the steepness of which is determined by several factors, especially the height of your Viral Load).
I did want to focus a bit on your observation that the decision to start antiretroviral therapy is "unreverseable". That makes it sound very ominous. I would look at it differently, as an opportunity to fight back against the virus. Right now you are anxiously awaiting each CD4 count and fretting over drops here and there, waiting for the number to hit 350. Once medication is started, yes, it is a commitment to take your meds regularly. It is almost always possible to find the right combo for anyone starting meds for the first time that they can tolerate. But, what you can gain is a full suppression of the virus and a reversal of the decline in CD4. Natural variations in CD4 counts are less worrisome when you know the virus is suppressed. It is true that once we start meds we prefer not to stop them, but that is only because it will allow the virus to start growing again, and you may loose the CD4 cells that you built up on meds, but that would leave you no worse off then where you would be if you never started at all.

Best, Joe