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Author Topic: Neurocognitive impairment linked to prior low CD4 cell count  (Read 5839 times)

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Online Miss Philicia

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source

Neurocognitive impairment linked to prior low CD4 cell count, even if on current suppressive HIV treatment
Liz Highleyman
Published: 26 July 2010

People who had a low CD4 cell count in past remain at greater risk for HIV-related neurocognitive impairment even after they start antiretroviral therapy and their immune status improves, participants heard in a late-breaker presentation at the Eighteenth International AIDS Conference last week in Vienna.

Neurocognitive problems among people with HIV -- ranging from mild impairment that can only be detected with specialised tests to debilitating AIDS dementia -- remain common in the era of effective antiretroviral treatment.

Investigators with the CHARTER (CNS HIV Antiretroviral Therapy Effects Research) study team assessed factors related to HIV-associated neurocognitive problems amongst more than 1500 participants evaluated at six university medical centres in the U.S.

Study participants underwent comprehensive, standardised neuropsychological assessments covering seven cognitive 'domains', or functional areas, as well as physical and neurological examinations. Researchers also looked at co-existing conditions and HIV-related measures including present and past CD4 cell count, obtained through medical records or self-report.

As reported by Igor Grant from the University of California at San Diego, approximately half of CHARTER participants were found to have some degree of cognitive impairment.

What's more, the investigators saw a consistent relationship between lowest-ever past CD4 cell count -- known as the 'nadir' -- and presence of impairment. Initial analysis showed that lower CD4 cell nadirs were strongly associated with neurocognitive impairment. This relationship remained statistically significant in an adjusted analysis taking into account a variety of demographic and clinical factors.

Amongst people whose CD4 count had ever dropped as low as 50 cells/mm3, approximately 60% showed some degree of impairment. But even amongst people with well-preserved immune function whose CD4 count had always remained above 350 cells/mm3  the likelihood stood at about 50%.

Current CD4 cell count, however, was not found be to a significant predictor of neurocognitive impairment.

Researchers then looked specifically at a subset of CHARTER participants who were on antiretroviral therapy and currently had undetectable viral load. Even within this group with currently well-controlled HIV disease, lowest-ever CD4 cell count was still a significant predictor of neurocognitive problems.

In response to a question from the audience, Grant said that whether an individual used antiretroviral drugs that were able to penetrate the blood-brain barrier to enter the central nervous system had only a "modest" effect.

These results led the CHARTER investigators to conclude, "HIV-associated neurocognitive disorders persist in many patients despite good immune recovery on [antiretroviral therapy]".

As to the implications of these findings, they said having ever had a low CD4 cell count may represent a 'legacy event' that has ongoing repercussions, including HIV-related brain injury and neurocognitive impairment that might not be fully reversible even with effective treatment later on.

Therefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes" in people with HIV.

 
"I’ve slept with enough men to know that I’m not gay"

Offline Nestor

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #1 on: July 26, 2010, 09:23:09 PM »
source

 What's more, the investigators saw a consistent relationship between lowest-ever past CD4 cell count -- known as the 'nadir' -- and presence of impairment. Initial analysis showed that lower CD4 cell nadirs were strongly associated with neurocognitive impairment. This relationship remained statistically significant in an adjusted analysis taking into account a variety of demographic and clinical factors.

Amongst people whose CD4 count had ever dropped as low as 50 cells/mm3, approximately 60% showed some degree of impairment. But even amongst people with well-preserved immune function whose CD4 count had always remained above 350 cells/mm3  the likelihood stood at about 50%.


The obvious question is what percent of people with nadirs higher than 350 had such impairment.  Among people whose nadir was 500, for example, what percent suffered impairment? 

Second question--if by neurocognitive impairment they mean everything "from mild impairment that can only be detected with specialised tests to debilitating AIDS dementia", then how were the various types of impairment distributed?  Of the 50% and the 60%, respectively, how many had debilitating dementia?  How many were only mild? 
Summer 2004--became HIV+
Dec. 2005--found out

Date          CD4    %       VL
Jan. '06    725    25      9,097
Nov. '06    671    34     52,202
Apr. '07    553    30      24,270
Sept. '07  685    27       4,849
Jan. '08    825    29       4,749
Mar. '08    751    30     16,026
Aug. '08    653    30       3,108
Oct. '08     819    28     10,046
Jan '09      547    31     13,000
May '09     645   25        6,478
Aug. '09    688   30      19,571
Nov. '09     641    27       9,598
Feb. '10     638    27       4,480
May '10      687      9    799,000 (CMV)
July '10      600     21      31,000
Nov '10      682     24     15,000
June '11     563    23     210,000 (blasto)
July  '11      530    22      39,000
Aug '11      677     22      21,000
Sept. '12    747     15      14,000

Offline mecch

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #2 on: July 26, 2010, 09:35:17 PM »
what if it was only low for a month during seroconversion? (not my case but just wondering)
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline Hellraiser

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #3 on: July 26, 2010, 09:37:32 PM »
How can they be sure this is related to HIV and not simply aging?  :P

Offline Nestor

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #4 on: July 26, 2010, 09:42:59 PM »
How can they be sure this is related to HIV and not simply aging?  :P

Good point!  Are they conducting such "specialized tests" on people who don't have HIV? 
Summer 2004--became HIV+
Dec. 2005--found out

Date          CD4    %       VL
Jan. '06    725    25      9,097
Nov. '06    671    34     52,202
Apr. '07    553    30      24,270
Sept. '07  685    27       4,849
Jan. '08    825    29       4,749
Mar. '08    751    30     16,026
Aug. '08    653    30       3,108
Oct. '08     819    28     10,046
Jan '09      547    31     13,000
May '09     645   25        6,478
Aug. '09    688   30      19,571
Nov. '09     641    27       9,598
Feb. '10     638    27       4,480
May '10      687      9    799,000 (CMV)
July '10      600     21      31,000
Nov '10      682     24     15,000
June '11     563    23     210,000 (blasto)
July  '11      530    22      39,000
Aug '11      677     22      21,000
Sept. '12    747     15      14,000

Offline leatherman

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #5 on: July 26, 2010, 09:51:51 PM »
more information about race, age, sex, and some other issues available at this links
http://www.natap.org/2010/IAS/IAS_66.htm
Nadir CD4 is a Predictor of HIV Neurocognitive Impairment (NCI) in the era of Combination Antiretroviral Therapy (CART): Results from the CHARTER Study

some of this same info was presented last year also
http://www.natap.org/2009/IAS/IAS_81.htm
Persistence and Progression of HIV-associated Neurocognitive Impairment (NCI) in the Era of Combination Antiretroviral Therapy (CART) and the Role of Comorbidities: The CHARTER Study 
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline Ann

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #6 on: July 26, 2010, 10:42:40 PM »
I've had a nadir of 281 and I don't have any.... um.... hang on, what was the question?
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline leatherman

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #7 on: July 27, 2010, 12:01:04 AM »
I've had a nadir of 281 and I don't have any.... um.... hang on, what was the question?
with a nadir of 5, I'm just going to claim I've lost my cognitive abilities the next time I get into a flamewar. LOL :D :D
(that is also my explanation for always using emoticons LOL)
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline tednlou2

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #8 on: July 27, 2010, 01:08:58 AM »
I've wondered about the nadir question when reading studies and whether my temporary CD4 of 171 would be considered my nadir.  I asked Dr. Gallant.  He said that temporary count would NOT count as my nadir. 

To Mecch's question:  If this is true, then I wouldn't think a low CD4 during seroconversion would count as your nadir.

Offline veritas

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #9 on: July 27, 2010, 05:37:54 AM »

Nestor,

Here's a study: http://www.ncbi.nlm.nih.gov/pubmed/18844464

The nadir is how far your cd4s fell to prior to starting haart. ie: if your put off starting meds till your cd4s drop to 200, your chance of having cognitive problems are higher than someone who starts at 350.

This is one of the issues driving the new guidelines to start meds between 350 and 500. Also, the ultra new thinking of starting meds as soon as you find out your poz.

v

Offline Ann

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #10 on: July 27, 2010, 06:35:29 AM »
I've wondered about the nadir question when reading studies and whether my temporary CD4 of 171 would be considered my nadir.  I asked Dr. Gallant.  He said that temporary count would NOT count as my nadir. 

To Mecch's question:  If this is true, then I wouldn't think a low CD4 during seroconversion would count as your nadir.

Well, I believe my doctor would beg to differ with ole Gallant. You might consider the number used as my nadir to be "temporary" as it occurred around the time I had shingles, but it is still the number my doc always lists as my nadir on his letters to my GP.

2004-01-28 VL 29,900 CD4 518 28%
2004-03-?? VL 07,370 CD4 281 23% had shingles
2004-06-01 VL 07,740 CD4 460 27%

Your CD4 nadir is the lowest CD4 count you have recorded. It's pretty simple.
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline phildinftlaudy

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #11 on: July 27, 2010, 07:58:03 AM »
with a nadir of 5, I'm just going to claim I've lost my cognitive abilities the next time I get into a flamewar. LOL :D :D
(that is also my explanation for always using emoticons LOL)
:) ;) :D ;D ::)
September 13, 2008 - diagnosed +
Labs:
Date    CD4    %   VL     Date  CD4  %   VL
10/08  636    35  510   9/09 473  38 2900  12/4/09 Atripla
12/09  540    30    60   
12/10  740    41  <48   
8/11    667    36  <20  
03/12  1,041  42  <20
05/12  1,241  47  <20
08/12   780    37  <20
11/12   549    35  <20
02/12  1,102  42  <20
11/12   549    35  <20

Offline mecch

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #12 on: July 27, 2010, 08:08:07 AM »
This is one of the issues driving the new guidelines to start meds between 350 and 500. Also, the ultra new thinking of starting meds as soon as you find out your poz.
v

Caveat : You mean the ultra new thinking of SOME docs in SOME regions in SOME countries.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline veritas

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #13 on: July 27, 2010, 08:41:14 AM »

Ann,

Your correct, your cd4 nadir would be the lower number since you haven't started Haart.

"These data suggest that prior duration of immune suppression does not predict subsequent recovery once ART is initiated and confirm the previous observation that the degree of CD4 depletion prior to ART initiation is the most important determinant of subsequent immune reconstitution."

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0011434

mecch,

That's correct, if they all agreed, it would be the new guideline. We have to see how it plays out.

v


Offline Ann

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #14 on: July 27, 2010, 09:57:29 AM »

Your correct, your cd4 nadir would be the lower number since you haven't started Haart.

It has nothing to do with whether or not I'm on meds. One's CD4 nadir is the lowest point their CD4 were ever recorded at, regardless of whether they're on treatment or not.

I actually asked my doc about this the first time I saw him use it. He told me that regardless of why it dropped so low that one time (had shingles a few weeks earlier, but was recovered at the time of the blood draw) it was still the one they used simply because it was the lowest ever recorded for me. That's what nadir means, lowest. I think he knows what he's talking about - he's a well-respected researcher as well as clinician. I mean for all we know, it could have been even lower while my shingles were still raging, but we don't have labs from then.

Your nadir is only one thing out of many to look at. It's still the trends over time that count the most.
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline Nestor

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #15 on: July 27, 2010, 10:21:41 AM »

Leatherman and Veritas, thanks for the links, which contain some interesting information.  But they too do not seem to contain the one thing that I would have thought necessary to make the case for earlier treatment. 


This is one of the issues driving the new guidelines to start meds between 350 and 500. Also, the ultra new thinking of starting meds as soon as you find out your poz.


In order to do that, they would have to show what the chances of cognitive impairment were of someone with a nadir of 400, 500, 600 etc.  All they have shown, in the original article, was that people with a nadir of 50 had a 60% chance of impairment, while those with a nadir of 350 had a 50% chance.  My main reaction was to be surprised at the smallness of the difference: it is significant, but still small.  The concluding line of the original article states:

Quote
herefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes" in people with HIV.

All this really means is "if you don't wait until you get down to 50 t-cells, you have a slightly smaller chance of cognitive impairment."  But nobody except Etay is arguing for going down to 50 t-cells.  The argument for most of us is about whether to start immediately (say with the 700 t-cells I had at my first test) or at around 500, or at around 350.  These articles do not contribute much to that argument. 

The study to which Veritas links above says only this:  of 26 people whose nadir was lower than 200, 19, or 73%, developed cognitive impairment, while, of 38 people whose nadir was above 200, only 20, or 52%, did so.  That again is an argument for not going down to below 200 t-cells, but I do not see where it supports "the ultra new thinking of starting meds as soon as you find out your poz."  By the way, since I can remember the days when "hit hard hit early" was the mantra--I have a friend who started ART with really good numbers because that was the trend of the moment--I would hesitate to describe this idea as "ultra new." 

I would have two questions regarding the use of the nadir as an important tool in predicting somebody's future outcomes.  Firstly, it leaves a tremendous amount to chance.  Most of us are getting labs only once every three months.  My doctor never tires of reminding me how greatly t-cells fluctuate.  Someone who had 700 t-cells in September and then 500 in December seems to have had a great decline, but there may have been no decline at all.  He might have had 500 t-cells the day before the 700; he might have had 700 two hours before the 500.  He might have had 900 t-cells three days earlier at six o'clock.  I tend to make the mistake of saying things like "the lowest CD4 count I've ever had was..." when what I mean is "the lowest CD4 count I happen to know about was....", because out of all of the millions of hours of the past four years, I only get tested for a handful of them.  Maybe there have been many times when I had 200 t-cells and it just so happens that I never got labs done at any of those times.  If Ann hadn't happened to get labs done at the moment when she had 281--if she had missed a train and had to reschedule the appointment for the next week--she would not now be someone with a nadir of 281 but something perhaps quite different.  Looked at in this light, it seems like a fairly flimsy premise on which to base any large plan. 

The second question has to do with the three quite different situations in which very low nadirs seem to occur.  First: during sero-conversion, as mentioned by Mecch; secondly, a temporary response to illness as in the case of Tednlou; thirdly, the end result of steady progression to AIDS.  Why would  these three very different cases lead to the same outcome?  I know about memory cells, but if a low t-cell count during sero-conversion already led to the loss of precious memory cells, then would we not all be in the same boat, as we all went through sero-conversion?
Summer 2004--became HIV+
Dec. 2005--found out

Date          CD4    %       VL
Jan. '06    725    25      9,097
Nov. '06    671    34     52,202
Apr. '07    553    30      24,270
Sept. '07  685    27       4,849
Jan. '08    825    29       4,749
Mar. '08    751    30     16,026
Aug. '08    653    30       3,108
Oct. '08     819    28     10,046
Jan '09      547    31     13,000
May '09     645   25        6,478
Aug. '09    688   30      19,571
Nov. '09     641    27       9,598
Feb. '10     638    27       4,480
May '10      687      9    799,000 (CMV)
July '10      600     21      31,000
Nov '10      682     24     15,000
June '11     563    23     210,000 (blasto)
July  '11      530    22      39,000
Aug '11      677     22      21,000
Sept. '12    747     15      14,000

Offline Ann

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #16 on: July 27, 2010, 10:38:04 AM »
If Ann hadn't happened to get labs done at the moment when she had 281--if she had missed a train and had to reschedule the appointment for the next week--she would not now be someone with a nadir of 281 but something perhaps quite different.  Looked at in this light, it seems like a fairly flimsy premise on which to base any large plan. 

I totally agree. As I mentioned, if I had gotten my labs done a few weeks earlier when I still had shingles, for all we know my CD4 nadir could have been even lower. Hell, it may have been higher. It may have been the same. Who knows? Our labs are only ever a brief snapshot in time, single pieces in a very large puzzle.

And before anyone says it, I did NOT have shingles because my CD4s were low. I had shingles because I was struggling with going back to work full time and having to travel to Liverpool for training courses. It was a very stressful time for me. The stress and shingles caused the dip in my numbers, not the other way around.
Condoms are a girl's best friend

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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #17 on: July 27, 2010, 12:34:34 PM »

The second question has to do with the three quite different situations in which very low nadirs seem to occur.  First: during sero-conversion, as mentioned by Mecch; secondly, a temporary response to illness as in the case of Tednlou; thirdly, the end result of steady progression to AIDS.  Why would  these three very different cases lead to the same outcome?  I know about memory cells, but if a low t-cell count during sero-conversion already led to the loss of precious memory cells, then would we not all be in the same boat, as we all went through sero-conversion?

Remember that these studies are correllational:  They do not state that a low cd4 inevitably leads to neurocognitive impairment, merely that persons whose nadir cd4 were recorded as low are MORE LIKELY than others to suffer neurocognitive impairment.  One of the most famous statistical quotes I know of...and one which is particularly meaningful here...is "correllation doesn't equal causation".  Just because your CD4 dropped temporarily because you're sick and your doc caught it, or because you started treatment midway through your "bounce" doesn't mean that you will be more likely to suffer impairment than someone who started observation long after their bounce but before decline during a particularly healthful month.  It merely means that, as a population, the average of persons who've been recorded with low nadir cd4 are more likely to experience  neurocognitive decline than the average of those who have not.   

As someone who has spent the last two months or so obsessing over cognitive decline, I'm going to caution all those with low nadirs to take any of these studies with a grain of salt.  The sad and scary truth is that the Big Brains in  academia don't seem to be able to agree on very much that is predictive of neurocognitive decline.  Nadir cd4 is without a doubt the most popular correllation, but there are literally dozens of recent studies floating around theinternet refuting this.  Other very popular correllations include coinfection with other STDs, particularly hep c & syphillis, race, age, anemia, previous education, type of drugs administered and god knows what else.  For every study which names any of the previously mentioned traits as predictive of neurocognitive decline, I can think of one that refutes or fails to address it entirely.  One very recent study I glanced over even stated that YOUTH...not advanced age but YOUTH, was predictive of neurocognitive decline.  The study admitted within their body that their results were both counterintuitive and divergent from the the vast majority research present.

These studies, as a whole, tend to have small sample sizes (ie far less than the 1500 Philly's had), poor demographic controls (they fail to determine whether the subjects were currently using drugs, etc) and rely on voluntary participation.  One physician's response stated out right that the last issue basically invalidated virtually every study as it all but ensured that the only participants would be those who were willing to give up two weekends for a $50 participation fee, a group which was already more likely to to be previously disabled or long term unemployed and therefore disproportionately affected by dozens of other factors which could themselves be predictive of HAND.  Additionally, double-blind testing (where neither the proctor nor the tested knows what the test is about) is vital for this type of test, and I simply can't imagine how you begin a study looking for HIV positive individuals, end it with a 3 hour long memory test, and not leave the tested individual with a pretty good idea that the purpose of the test was to see if their bug was making them stupid.

In other words, these studies..all of them...are bad.

What the studies DO agree on is that those with HIV tend to be more likely than the general population to suffer a degree of cognitive decline. typically, I see us as having something around a 50% rate of decline, versus a 5% rate of similar decline in the negative population.  What they also agree on is that most of these cases are "asymptomatic"..that is, they aren't observable to the person experiencing them, to the people that person knows, or even a trained professional looking for them, without the use of specific psychological tests.  Whether the cumulative effects of years of asymptomatic neurocognitive decline leads to symptomatic decline or not isn't something I've been able to read anything about. 
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline Boze

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #18 on: July 27, 2010, 12:54:57 PM »
I find it rather funny that no matter what new studies come out, some people like to hang on to their 'anti-haart above 350' views.

Isn't it  pretty straightforward - the virus fucks you up. The longer you wait, the more damage it does. We see more and more research on this almost on a weekly basis.
==========
Aug08 - Seroconversion
Mar10 - Diagnosis; cd4 690 - VL 19,000
Apr10 - cd4 600
May10 - VL 4,500
Jun10 - started Atripla ; VL 113
Jul 10 - UD vl, CD4 590
Aug 10 - UD, CD4 810, 52%
Nov 10 - UD, CD4 980

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #19 on: July 27, 2010, 12:59:47 PM »
I find it rather funny that no matter what new studies come out, some people like to hang on to their 'anti-haart above 350' views.

Isn't it  pretty straightforward - the virus fucks you up. The longer you wait, the more damage it does. We see more and more research on this almost on a weekly basis.

And the drugs also fuck you up Boze.  The reasonable party tries to balance the two out.

On an aside, I dont think anyone...including the study's authors...are trying to make the case that HAART will prevent neurocognitive decline by facilitating higher CD4 numbers.

"Therefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes"

May is different than will, even the researchers aren't going so far as to say that this is definitely a path to healther living.
« Last Edit: July 27, 2010, 01:05:51 PM by wtfimpoz »
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline veritas

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #20 on: July 27, 2010, 01:37:58 PM »

As a general rule, nothing with this disease is black and white. All these posts have valid points. The research tells us, this is what has been observed in this study. Does this mean it will happen to everyone? Of course not. Take for instance the cd4 nadir. How about an hiv- person with a a low cd4 nadir. Do they have a risk for potential neurocognitive decline? Lets take a look at just cd4s. Some have a cd4 count of 300 (HIV-) and thats "normal" for them. No one number is the tell all. Everything with respect to your health  has to be taken on a personal level covering all YOUR OWN parameters. A lot of these questions can't be answered yet. We can only follow statistical  trends. Take Ann for instance. She is a LTNP.Something in her chemistry is different. Her nadir might not mean anything other than a number. We just don't know. When reading these studies, keep the aforementioned in mind. It's a balance.

v

Offline Nestor

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #21 on: July 27, 2010, 02:42:18 PM »


In other words, these studies..all of them...are bad.



That just about hits the nail right on the head!
Summer 2004--became HIV+
Dec. 2005--found out

Date          CD4    %       VL
Jan. '06    725    25      9,097
Nov. '06    671    34     52,202
Apr. '07    553    30      24,270
Sept. '07  685    27       4,849
Jan. '08    825    29       4,749
Mar. '08    751    30     16,026
Aug. '08    653    30       3,108
Oct. '08     819    28     10,046
Jan '09      547    31     13,000
May '09     645   25        6,478
Aug. '09    688   30      19,571
Nov. '09     641    27       9,598
Feb. '10     638    27       4,480
May '10      687      9    799,000 (CMV)
July '10      600     21      31,000
Nov '10      682     24     15,000
June '11     563    23     210,000 (blasto)
July  '11      530    22      39,000
Aug '11      677     22      21,000
Sept. '12    747     15      14,000

Offline Nestor

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #22 on: July 27, 2010, 03:14:20 PM »
I find it rather funny that no matter what new studies come out, some people like to hang on to their 'anti-haart above 350' views.
 

Why should it be funny when none of the new studies so far have come remotely close to providing a reason for us to relinquish those views?  Suppose the study above had gone on to say: "among people with a nadir of 500 t-cells, only ten percent had cognitive impairment."  Wow.  Now that would be a real, gold-standard, red-meat argument for starting meds at any number.  But it says no such thing; it doesn't even address the question of CD4 counts above 350, except by implication.  The original article doesn't even attempt to "spin" it that way--it only says:

Therefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes" in people with HIV.

You don't have to start above 500 to prevent "severe immunosuppression".  350 t-cells is not "severe immunosuppression." 

Quote
Isn't it  pretty straightforward - the virus fucks you up. The longer you wait, the more damage it does. We see more and more research on this almost on a weekly basis.

I've seen more and more rhetoric about this on an almost weekly basis, but not more and more research. 
Summer 2004--became HIV+
Dec. 2005--found out

Date          CD4    %       VL
Jan. '06    725    25      9,097
Nov. '06    671    34     52,202
Apr. '07    553    30      24,270
Sept. '07  685    27       4,849
Jan. '08    825    29       4,749
Mar. '08    751    30     16,026
Aug. '08    653    30       3,108
Oct. '08     819    28     10,046
Jan '09      547    31     13,000
May '09     645   25        6,478
Aug. '09    688   30      19,571
Nov. '09     641    27       9,598
Feb. '10     638    27       4,480
May '10      687      9    799,000 (CMV)
July '10      600     21      31,000
Nov '10      682     24     15,000
June '11     563    23     210,000 (blasto)
July  '11      530    22      39,000
Aug '11      677     22      21,000
Sept. '12    747     15      14,000

Offline mecch

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #23 on: July 27, 2010, 03:35:31 PM »
Believe what you feel in your gut about when to start HAART - 200, 350, 500, 747, seroconversion, pre-exposure prevention. whatever.
You can find a good doctor who will agree with your gut belief. Just don't wait "too too" long. :) 
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline Boze

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #24 on: July 27, 2010, 05:13:57 PM »
And the drugs also fuck you up Boze.  The reasonable party tries to balance the two out.

On an aside, I dont think anyone...including the study's authors...are trying to make the case that HAART will prevent neurocognitive decline by facilitating higher CD4 numbers.

"Therefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes"

May is different than will, even the researchers aren't going so far as to say that this is definitely a path to healther living.

That's exactly what they are saying. That's how scientists phrase things - in very neutral, couched wording. If you email the study authors directly and ask them, i'm sure they'll recommend early start based on what they observed.

Why should it be funny when none of the new studies so far have come remotely close to providing a reason for us to relinquish those views?  Suppose the study above had gone on to say: "among people with a nadir of 500 t-cells, only ten percent had cognitive impairment."  Wow.  Now that would be a real, gold-standard, red-meat argument for starting meds at any number.  But it says no such thing; it doesn't even address the question of CD4 counts above 350, except by implication.  The original article doesn't even attempt to "spin" it that way--it only says:

Therefore, they suggested, preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes" in people with HIV.

You don't have to start above 500 to prevent "severe immunosuppression".  350 t-cells is not "severe immunosuppression." 

I've seen more and more rhetoric about this on an almost weekly basis, but not more and more research. 

Your attitude reminds me of this joke:


There was a guy drowing in the ocean. He prayed to God to save him.

A few minutes later a boat came and offered to pick him up and take him to shore. The drowning man refuesed and the boat left.

Another boat came and offered to save the man and he said no, and the boat left.

Finally a third boat came and said I can help you. Once again the drowing man said no.

When he died he said to God: I trusted you. Why didn't you save me??
God said: I sent you 3 boats!!!!!!!!!!

-------

==========
Aug08 - Seroconversion
Mar10 - Diagnosis; cd4 690 - VL 19,000
Apr10 - cd4 600
May10 - VL 4,500
Jun10 - started Atripla ; VL 113
Jul 10 - UD vl, CD4 590
Aug 10 - UD, CD4 810, 52%
Nov 10 - UD, CD4 980

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #25 on: July 27, 2010, 05:30:23 PM »
NO boze, if he had any sense of responsibility he wouldn't recommend shit until settled medical opinion jived with his findings.  The very reason they couch their wording in political language is because individual peices of research have a long history of being wrong, and they know they may be wrong too.  Consensus based on research has a long history of being wrong.  This is why every worthwile country has extensive testing and approval standards for virtually every medical act, this is why even in the US its fucking IMPOSSIBLE to get a physician to prescribe shit off label based on a few studies, and this is why if I emailed the scientists who wrote the study, they absolutely would not say anything more meaningful than "our research shows a generalized decrease in liklihood of neurocognitive decline with higher nadir cd4 counts".  BECAUSE THEY DONT REALLY FUCKING KNOW, AND THEY KNOW THEY DON'T KNOW! They may *believe* it, but they don't fucking know it.

Boze, HAART is not "a gift from god", its an expensive, debilitating series of medical treatments.  There are various pros and cons to starting it at any given point in time.  For almost all of us, we're better off using it than not.  That said, it is not necessarily a treatment where "more is better".  Its hardly settled science that it is better started at 800, or even 500 cd4 than it is at 350.  I keep seeing you describe the situation in terms that condescend to those of us with the virus...the docs are "parents", and we're children, HAART is a fisherman and we're drowning.  The situation isn't nearly that black and white though.  I'm glad that youre comfortable with your decision to start early, and I'll probably be starting in a few more weeks based on my own personal level of comfort with my situation, but don't think for a minute that your decision, or mine, is one that we should feel comfortable recommending to others.
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline newt

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #26 on: July 27, 2010, 05:36:58 PM »
That boat thing really isn't a good analogy. There's a world of difference between a CD nadir of 50 and the effects of long term serious immune depletion over several year and a CD nadir of 250 or 350.

There is no strong evidence yet to suggest starting treatment above a CD4 count of 350, strong evidence for below 350 and suggestive evidence that leads to differing opinions with counts between 350 and 500. Plus it's a study in a solely American cohort, who have worse health outcomes (possibly, well certainly related to underinsurance/no insurance - see excess death/heath attack rate in SMART study of US people v Europe).

This is an important topic and the evidence is likely to get worse, ie favour cognitive impairment to some degree, but whether very early/immediate treatment will rectify this is a moot point, since maybe the damage is done in the first weeks of infection before it is detected.

Yes, brain fog is real, but may is a key word here.

I like the previous poster's comments too.

- matt
"The object is to be a well patient, not a good patient"

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #27 on: July 27, 2010, 07:49:28 PM »
As per the nadir question, most people's nadir probably occurs right before they begin treatment, so by default nadir stands as a proxy for the degree of overall damage done to a person's body for the virus.  Ann, while technically having a low "nadir" would probably not follow what would be expected from this study.  Of course,  what I've come to observe in these types of epidemiological surveys is that if Ann's numbers skew the answer they want, she'd simply be deleted as an outlier or explained away in a discussion of the results.    

EDIT:  I think the numerous personal accounts of "brain fog" provide probably the most compelling evidence for the presence of cognitive decline in those with HIV.  That said, many of them are apparently as much a result of the drugs being taken as the effects of the virus themselves, as many people even on this forum seem to indicate that their problems are occasionally remedied by new drug choices.  Others, such as that Scot Charles guy from TheBody.com, clearly have over-arching psychological and medical problems which make it difficult to isolate HIV as the culprit.  Cognitive decline is probably the scariest thing about HIV, but also one of the most ambiguous.  I'm curious to see the perspectives of long term survivors on the subject.
« Last Edit: July 27, 2010, 07:58:14 PM by wtfimpoz »
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline Hellraiser

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #28 on: July 27, 2010, 09:21:53 PM »
The reason science and medicine don't use absolutes is because it's very difficult to be 100% correct with anything.  It's not that they don't "know".  There is usually an idea and a general trend and when enough of those corroborate each other they begin to think of it as fact unless some major evidence points to the contrary.

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #29 on: July 31, 2010, 04:56:48 PM »

You don't have to start above 500 to prevent "severe immunosuppression".  350 t-cells is not "severe immunosuppression." 

Which is another thing.  I'm working off memory here, so if im getting the exact numbers wrong, forgive me.  Am I the only one who found it odd that in this study, FIFTY percent of those beginning treatment above 500 nadir cd4 still had cognitive decline while only 60 percent with a nadir of 50 suffered it?  This might be significant on a mathematical level, but thats about it really doesnt' scream out that HAART does a very good job of preventing HAND. 
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline Boze

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  • Posts: 477
Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #30 on: July 31, 2010, 06:29:18 PM »
Which is another thing.  I'm working off memory here, so if im getting the exact numbers wrong, forgive me.  Am I the only one who found it odd that in this study, FIFTY percent of those beginning treatment above 500 nadir cd4 still had cognitive decline while only 60 percent with a nadir of 50 suffered it?  This might be significant on a mathematical level, but thats about it really doesnt' scream out that HAART does a very good job of preventing HAND. 

I don't know why you have to work off memory when the data are at the top of the thread :)

"Amongst people whose CD4 count had ever dropped as low as 50 cells/mm3, approximately 60% showed some degree of impairment. But even amongst people with well-preserved immune function whose CD4 count had always remained above 350 cells/mm3  the likelihood stood at about 50%."

So they compare 50 cd4 and 350 cd4. BUT - since NORMAL cd4 is upward of 500, I reckon that 350 already represents a somewhat compromised immune function. Maybe it's not even about the immune system per se - but rather it's a marker for how advanced HIV is. In other words - it may be doing some nasty things to one's body when the body and cd4 count represents a progress report of its advancement.
==========
Aug08 - Seroconversion
Mar10 - Diagnosis; cd4 690 - VL 19,000
Apr10 - cd4 600
May10 - VL 4,500
Jun10 - started Atripla ; VL 113
Jul 10 - UD vl, CD4 590
Aug 10 - UD, CD4 810, 52%
Nov 10 - UD, CD4 980

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #31 on: July 31, 2010, 06:45:51 PM »
Yeah, that was my guess too...that its a marker of the degree of damage HIV has done.  Still, the difference between 350 and 50 is years, and a lot of other damage.  Its scary to know that this only results in a 20% increase in hand rates.  I'd honestly love to learn more about the experimental design of these studies, what the threshold is for "cognitive decline", how they selected their experimental populations, what the rate of decline is in the control, etc.   
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline max123

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #32 on: July 31, 2010, 08:30:51 PM »
I'm glad that youre comfortable with your decision to start early, and I'll probably be starting in a few more weeks based on my own personal level of comfort with my situation, but don't think for a minute that your decision, or mine, is one that we should feel comfortable recommending to others.

why not?
1/86 - 6/08 (annually): neg elisa
7/09: pos elisa/pos wb
8/09: cd4 560, cd4% 35, vl 13,050
12/09: cd4 568, cd4% 33, vl 2,690
4/10: cd4 557, cd4% 29.3, vl 6,440
7/10: cd4 562, cd4% 29.6, vl 3,780

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #33 on: July 31, 2010, 08:33:23 PM »
why not?

Because neither of us KNOWS its the right choice.

EDIT:  And without knowing, its probably not appropriate to recommend it to someone who is incapable of understanding the pros and cons of the medication, that our recommendations are possibly incorrect, etc. 
« Last Edit: July 31, 2010, 08:37:30 PM by wtfimpoz »
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline max123

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #34 on: July 31, 2010, 08:38:10 PM »
Which is another thing.  I'm working off memory here, so if im getting the exact numbers wrong, forgive me.  Am I the only one who found it odd that in this study, FIFTY percent of those beginning treatment above 500 nadir cd4 still had cognitive decline while only 60 percent with a nadir of 50 suffered it?  This might be significant on a mathematical level, but thats about it really doesnt' scream out that HAART does a very good job of preventing HAND. 
does the study specifically reference the number of participants that started above cd4 500 that took blood-brain barrier penetrable haart vs non blood-brain barrier penetrable haart?
1/86 - 6/08 (annually): neg elisa
7/09: pos elisa/pos wb
8/09: cd4 560, cd4% 35, vl 13,050
12/09: cd4 568, cd4% 33, vl 2,690
4/10: cd4 557, cd4% 29.3, vl 6,440
7/10: cd4 562, cd4% 29.6, vl 3,780

Offline max123

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #35 on: July 31, 2010, 08:39:15 PM »
Because neither of us KNOWS its the right choice.

EDIT:  And without knowing, its probably not appropriate to recommend it to someone who is incapable of understanding the pros and cons of the medication, that our recommendations are possibly incorrect, etc. 
then why are you doing it?
1/86 - 6/08 (annually): neg elisa
7/09: pos elisa/pos wb
8/09: cd4 560, cd4% 35, vl 13,050
12/09: cd4 568, cd4% 33, vl 2,690
4/10: cd4 557, cd4% 29.3, vl 6,440
7/10: cd4 562, cd4% 29.6, vl 3,780

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #36 on: July 31, 2010, 09:14:44 PM »
1)  Partnered and would like to be less infectious.
2)  Am personally choosing the devil I don't know (long term side effects) over the devil I do know (greater liklihood of cognitive decline, various health issues related to HIV).  This is a purely subjective assesment of the issues as they relate to me.  I wouldn't know whether a third party would be willing to exchange, say, their bone density for a SLIGHT decrease in the liklihood of cognitive issues.  It makes sense to me, but without knowing THEIR priorities, I wouldn't blurt out "everyone should start immediately".
3)  My CD4 level is like 423, WAY lower than I thought it would be.  If I am in fact in the middle of a post-infection bounce, and it is much higher at my next test, I may wait a while further, but if it is not, I seem to be deteriorating rapidly, and I'd rather not sit around and wait for it to skip down to, say, 70 in a few months before I decide that I'm "comfortable" or that the bounce I was waiting for isn't going to happen.
4)  I was raised in a culture and am of a mindeset in which its always deemed better to do SOMETHING and risk losing everything because of that something, than to do NOTHING and watch everything slowly slip away.  Again, this is a values-based decision and shouldn't be used by any other person.  And yes, it is likely related to the illusion that I'm actually clearing myself of the virus.
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #37 on: July 31, 2010, 09:16:34 PM »
does the study specifically reference the number of participants that started above cd4 500 that took blood-brain barrier penetrable haart vs non blood-brain barrier penetrable haart?

Not that I noted.  I think it stated that blood/brain HAART showed modest or minor decreases, but didn't specify anything.  Thats another trend i've seen in lots ot studies.  Blood/brain penetration has modest or negative help with HAND.
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline max123

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #38 on: July 31, 2010, 09:58:52 PM »
wtf,

ok, i was simply asking out of curiosity. that said: 1) understood 2) thanks for clarifying (since you had posted earlier in this thread, For almost all of us, we're better off using it than not, i figured i'd see what you meant. 3) i wasn't sure you were going to wait & see what your next labs showed given your post in another thread that you were going to start meds in a few weeks. 4) understood.

regarding blood-brain barrier penetration, i believe i had read that this was one of the big questions regarding the possible neurocognitive benefits of isentress, but again, long term data appears to be limited given its relative newness.
1/86 - 6/08 (annually): neg elisa
7/09: pos elisa/pos wb
8/09: cd4 560, cd4% 35, vl 13,050
12/09: cd4 568, cd4% 33, vl 2,690
4/10: cd4 557, cd4% 29.3, vl 6,440
7/10: cd4 562, cd4% 29.6, vl 3,780

Offline leatherman

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #39 on: July 31, 2010, 11:07:18 PM »
4)  I was raised in a culture and am of a mindeset in which its always deemed better to do SOMETHING and risk losing everything because of that something, than to do NOTHING and watch everything slowly slip away.
the good thing is that doing something against HIV does not entail the risk of losing everything. Unfortunately doing nothing against HIV does mean losing everything, as the outcome of an untreated HIV infection leads to death. Doing something, taking action against the HIV, almost always postpones the evitable. Instead of risking everything, it' a net gain.

I, as others did, took azt monotherapy. The negative effects I suffered back then were most certainly outweighed by the fact I'm still alive 18 yrs later. Just like having a little brain fog and staying alive for another 30 or 40 yrs. isn't a bad trade-off for not being dead. Not to diminish anyone's problems but to have quality of life issues first means that you need to have a life.

And yes, it is likely related to the illusion that I'm actually clearing myself of the virus.
I'm sure people with diabetes, cancer, etc. waste some time with that illusion too. However, it's always best to live in the real world - especially this world in which meds have been developed that have proven success in a positive treatment (sadly not a cure..yet, but at least a positive treatment)
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #40 on: July 31, 2010, 11:16:48 PM »
the good thing is that doing something against HIV does not entail the risk of losing everything. Unfortunately doing nothing against HIV does mean losing everything, as the outcome of an untreated HIV infection leads to death. Doing something, taking action against the HIV, almost always postpones the evitable. Instead of risking everything, it' a net gain.

I, as others did, took azt monotherapy. The negative effects I suffered back then were most certainly outweighed by the fact I'm still alive 18 yrs later. Just like having a little brain fog and staying alive for another 30 or 40 yrs. isn't a bad trade-off for not being dead. Not to diminish anyone's problems but to have quality of life issues first means that you need to have a life.
I'm sure people with diabetes, cancer, etc. waste some time with that illusion too. However, it's always best to live in the real world - especially this world in which meds have been developed that have proven success in a positive treatment (sadly not a cure..yet, but at least a positive treatment)

Very interesting perspective, and very true.
09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

Offline OneTampa

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #41 on: August 02, 2010, 02:39:06 PM »
Agreed.
"He is my oldest child. The shy and retiring one over there with the Haitian headdress serving pescaíto frito."

Offline eric48

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #42 on: August 08, 2010, 11:39:42 AM »
Back to cognitive impairments. Some meds go into your CNS, some don't. As they go into your brains they may protect you as well as make your life miserable. I had told my doc that this was my primary concern (above recovery speed, Lipo, diabetes, cholesterol, number of dose, etc)
That's why he put me on viramune (despite the higher SE risk, since my CD4 > 400) and Kivexa (again risky because of abacavir...).

Everyone on this forum seems to be fine though

I'll keep my finger crossed ... Shit, I just realized I can't uncross them anymore...

Cheers!! Eric
NVP/ABC/3TC/... UD; CD4 > 1000; CD4/CD8 ~ 2.0

Offline tommy246

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #43 on: August 08, 2010, 03:36:25 PM »
as ann says your nadir is your lowest point but i think that long term damage could be done if you have a very low nadir for a number of years and not the fact that someone might dip to a low cd4 count for week or two if sick. My numbers crashed when i had pneumonia last year but a week later they had shot up again so whilst my nadir is 191 when hospitalised it was only at that for days so i personally consider my lowest point to be around the 500-600 mark
jan 06 neg
dec 08 pos cd4 505 ,16%, 1,500vl
april 09 cd4 635 ,16%,60,000
july 09 ,cd4 545,17%,80,000
aug 09,hosptal 18days pneumonia cd190,225,000,15%
1 week later cd4 415 20%
nov 09 cd4 591 ,vl 59,000,14%,started atripla
dec 09  cd4 787, vl 266, 16%
march 2010  cd4 720 vl non detectable -20  20%
june 2010  cd4  680, 21%, ND

Offline leatherman

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #44 on: August 08, 2010, 04:10:58 PM »
as ann says your nadir is your lowest point but i think that long term damage could be done if you have a very low nadir for a number of years and not the fact that someone might dip to a low cd4 count for week or two if sick. My numbers crashed when i had pneumonia last year but a week later they had shot up again so whilst my nadir is 191 when hospitalised it was only at that for days so i personally consider my lowest point to be around the 500-600 mark
it will be interesting to see further study about this issue.

Think for a minute about, say, a broken arm. After it was broken and had mended, even without lingering weakness, the bone would be forever compromised and the area of that break usually remains a weak spot, easily susceptible to re-breaking at the same location. (during the time I did computer work for several auto body shops, I saw this in principle. Once a car is wrecked, no matter how well it is repaired, it almost always remains slightly "out of alignment", never quite the same as it was before the stress of the accident changed it's structure forever)

I understand your point that a sustained low cd4 period would have much greater damage, perhaps a longer recovery time, and maybe long term or lingering side effects. I myself spent several intervals of months at a time (probably adding up to several years) under treatment with my cd4 counts under 100 - heck under 50. I'm sure it took 18 yrs to get up to my all-time high of 318 because of that sustained systemic damage. Even though I am much healthier these days, I can still feel the tell-tale signs of the decade plus of time (from 1992 to 2004) that I spent living in an actual AIDS category (of under 200, dealing with multiple OIs)

However, regardless of whether it is a short time or long time spent near the nadir, your immune system was weakened to that extent. I would imagine that as time progresses and they continue studying this issue, they will be able to more aptly determine if the issue lies with just hitting such a nadir (ie <50 or something) or from the sustained time of having your immune system compromised so badly.

luckily, shy of a little brain fog once in a while, my brain seems to still be functioning well enough (now, now. no wisecracks from the peanut gallery LOL :D ) as 48 itself, hereditary of a grandparent with Alzheimer's and years worth of time with incredibly low cd4 counts seem to not be impinging on my brain functions.... yet ROFLMAO. Thankfully, like with all side effects, none are universal and only a portion of people are effected.; so I'm hoping I'm in the 40% who don't have cognitive issues. ;)
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline wtfimpoz

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Re: Neurocognitive impairment linked to prior low CD4 cell count
« Reply #45 on: August 08, 2010, 04:31:01 PM »
Back to cognitive impairments. Some meds go into your CNS, some don't. As they go into your brains they may protect you as well as make your life miserable. I had told my doc that this was my primary concern (above recovery speed, Lipo, diabetes, cholesterol, number of dose, etc)
That's why he put me on viramune (despite the higher SE risk, since my CD4 > 400) and Kivexa (again risky because of abacavir...).

Everyone on this forum seems to be fine though

I'll keep my finger crossed ... Shit, I just realized I can't uncross them anymore...

Cheers!! Eric

are there any studies regarding the crossing of the blood brain barrier which indicate greater resilience to hand?  I have not seen one with a strong correllayion and recall a few where blood brain barrier crossing made things worse.  We assume that because azt virtually eliminated aids dementia that blood brain crossing is *the way* but I know of no haart studies that prove this.  What's more we don't know if hand is the result of the virus on the brain, inflammation, something we don't understand or even some kind of social variable.  Finally I'm not a doctor here bur generations of my family have been afflicted by diabetes.  I'd ask you to visit a nursing home and see the result of years if "low blood sugar incidents" before you willingly trade anything for diabetes.  You may find that the cure is as bad a the disease here.

09/01/2009-neg
mid april, 2010, "flu like illness".
06/01/2010-weakly reactive ELISA, indeterminant WB
06/06/2010-reactive ELISA, confirmed positive.

DATE       CD4     %     VL
07/15/10  423     33    88k
08/28/10  489     19    189k
09/06/10-Started ATRIPLA
09/15/10  420     38    1400
11/21/10  517     25    51

 


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