Meds, Mind, Body & Benefits > Questions About Treatment & Side Effects

CD4% info and Trend after treatment

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new_2013:
Hi,
   I am looking for more information regarding CD4% specifically and its link to starting meds and if there is any expected "trend" after starting treatment. Most of the info I have seen discusses CD4 count and VL.

I was diagnosed in January 2013 and my recent clinic appointment my doctor is recommending I start treatment now and I believe the main reason is my low CD4% (I live in the UK).  She is recommending Kivexa(Epzicom) AND (Efavirenz OR Rilpivitine)

10th Jan - CD4 - 507 / VL - 1669 /        CD4% - 19%
24th Jan - CD4 - 482 / VL - unknown  / CD4% - 21%
26th Apr - CD4 - 438 / VL - 98906 /      CD4% - 18%
09th Jul  - CD4 - 480 / VL - 54748 /      CD4% - 20%
14th Oct - CD4 - 432 / VL - 29197 /      CD4% - 16%

I came across this on the web (I do appreciate everyone will react differently so its just a reference to a trend)
During the first two months of therapy, an HIV-infected person's viral load should drop a minimum of 90%. In other words, someone who starts treatment with a viral load count of 100,000 should drop to 10,000 or less within two months. Within 4 to 6 months of starting therapy, the viral load should have dropped a lot more, hopefully below the level of the viral load test's sensitivity ("undetectable").

As for your CD4 cell count, you will likely see an increase between 100 and 200 cells in the first 12 to 18 months, and can gradually climb from there as long as viral load remains undetectable. Some people who start HIV treatment for the first time have a poor CD4 response despite achieving and maintaining an undetectable viral load. Researchers refer to individuals in this situation as "discordant responders." Most discordant responders waited to start treatment until their CD4 counts were well below 200. This is one of the reasons that the guidelines recommend starting ARVs earlier.

Does a similar expectation around CD4% exist?
Does anyone have a link to any information around CD4% in this range?

Thanks in advance ;-)


 

eric48:
Hi,

I started treatment as my numbers were similar to your July numbers. I take Epzicom (aka kivexa) and Viramune (as Riilripine was not available at that time)

If I had to choose between EFV and riviliripine, I'd take the later.

You can follow my experience on Epzicom here
www.tinyurl.com/HIVPharmaCure

You'll see some numbers. aand graphs towards the bottom of the thread

My doc did not push me into treatment as he was not excluding the possibility to be a controller (but this is rare). Seeing your VL going down steadily, you may want to consider postponing and see.

You are not in critical condition. Me I have never got sick

CD4 increase is a good indicator to see if people are immuno responders, but, it is biased in one way. If you consider that the average CD4 count is about 800, the potential for recovery is not the same if you start at 100 or at 700.

CD4 dynamics are poorly undertood and modelized.

Mine went up quickly to 600 - 700 where I had expected them to be.

The last summer I had a +700 jump in 2 months to reach 1400. I thought it was a lab error but later data confirmed.

A vast majority will respond both virologically and immunologically, so you should not worry. Moreover, in the (rare) case were you count gain would be modest, you are starting from a fairly safe zone, so you would at least remain where you had started from, which would provide way enough CD4 to feel safe

Epzicom is not for everyone, but those who tolerate seem to tolerate without much complaints

I do have a CD4% range table that I'll post soon (I do not have it at hand)

Your % is below range. In my case this was one factor for starting meds, but also my age (being older). The lower CD4% you have demonstrate that the CD8% is up (may be in the 50-60% , am I correct ?), they are doing their job, trying to control the infection

% recovery is not a popular concept, but you will find more lit. on the CD4/CD8 ratio
fav
70% of people under treatment will not normalize this ratio, while 30% will. Yet, depite it is conforting to normalze every thing, the is not smoking gun that says people with a non-normalized ratio are at a higher rish, or if, so this is most likely marginal (I hope...). Bear in mind that you are currently at a CD4 count way above where most people have started treatment (in the past)

Factor that favorably help normalizing the percentages are younger age, earlier treatment (before 1 year), use of NVP (sex, wine, etc. should help too!)

Hope this helps

Cheers

Eric

leatherman:
some thoughts about cd4 counts - and why NOT to worry about them

1) they can change by 100 pts a day
     so that means you can never determine anything by just one test. it's the trend over 3 or 4 tests that really gives the picture of what you count is
2) they are higher in the evening than the morning
     so getting tested around the same time of day somewhat helps with keeping more consistent labs
3) normal is 500 to 1500
    so don't get bogged down on worrying that cd4 counts aren't climbing more or faster, because that's a big damn range.
4) without having been tested BEFORE HIV, no one knows their "normal" count
5) at a certain point, it's not how many you have; but how well they work
     reading stories here, I would venture to say that my 305 (at 28 yrs poz) has kept me healthier than many in the 700-1000 range. I'm not bragging, just pointing out that more isn't always better
6) dropping to a low nadir (lowest point) can result in slow recovery and not a very large recovery

this doesn't mean that cd4 count isn't important; but the goal of ART is to reduce viral load and allow cd4s to recover. Staying UD (undetectable) is of much more importance than what your cd4 count is.


--- Quote from: new_2013 on November 02, 2013, 11:23:37 AM ---I was diagnosed in January 2013 and my recent clinic appointment my doctor is recommending I start treatment now and I believe the main reason is my low CD4% (I live in the UK).

--- End quote ---
recommendations are that meds should be started <500 cd4s. your trend clearly reflects that recommendation.  ;)

new_2013:
Thanks Eric for your response, I had actually seen your posts earlier regarding Epzicom and found it very useful.

Thanks also leatherman for your response, also very helpful (and the quote from les mis is very touching).

I suppose where I am coming from is I don't see any reason for immediate alarm with my CD count and VL. My plan was if my CD count went below 400 or VL > 100,000 I would start meds.

My main query is my CD% which was 16% about 3 weeks ago. I am finding it hard to get any clear reference on this besides that it is low and is also a trigger to starting meds. I am also slightly concerned about references i see like "AIDS is diagnosed when an HIV-positive person's immune system deteriorates to a specific point (CD4 count of 200 or CD4% of 14%)"

With a CD of 16% should I be feeling alarmed and request meds ASAP?
Is there a "trend" for improvement in this figure after starting meds?

eric48:
Hi,

If you had been through the thread I maintain to keep V&K users posted about latest on these meds, you'll see some post coming and discussing CD4%. I am preparing them, so...they are not ready...

I found a good reference for the data you want:
http://www.uams.edu/clinlab/flow.htm

CD3:  64-82%, 1171-2005/Ál
CD4:  39-57%, 720-1348/Ál
CD8:  17-31%, 318-710/Ál
CD19:  8-16%, 151-343/Ál
CD16/56:  7-21, 145-453/Ál
H/S Ratio 1.0-3.6

The H/S ratio can be calculated by dividing CD4% by CD8%.

I understand the concern with the CD4% reading at 16. It seems to have come down, but, there may be an alternative way of looking at things. For this the CD8 % data are needed.

the % vs disease progression risk shows a cliff pattern
16% is in safe zone (plateau)
15% also
14 % cliff
13 % enter serious concern

As long as you are on the plateau, it does not seem to matter if you are close to the cliff or not.

14% used to be (may be still is) a AIDS defining number as per CDC classification, but, I think there was some discussion about removing it as an event as it is more a risk. In some countries it is no more used for classification.

Yet, I wanted my bill clean of the 4 letter word, so I opted for meds.

Looking back... Well it is too late to look back.

The other day I played bad kid and I teased my doc saying:
earlier into treatment, earlier off treatment

He did not like the pun, but I am hopeful that they will find a solution, especially to allow some patients be ON-OFF. Patients allowed to do that will obviously those who have been fairing well in treatment. Initiating treatment early should favor better outcome, hence be eligible for future 'tweaks' if they ever come out.

You doc did not offer your NVP since your CD4 > 400

If you start at CD4 < 400 you can consider viramune (250 for ladies)

If you start at CD4 > 400 you can consider another NNRTI and then switch to V ( if you are uncomfortable with that NNRTI) after some month, because the ban on CD4> 400 is only for treatment naives (and after a few months, you are no more treatment naive). If you consider this strategy, then starting with EFV is better than starting with rivilripine.

This partially has to do with the size of the molecule, since NNRTIs have a steric action (they block passage by sitting in the middle of the road). Smaller molecule, better penetration, larger molecule better blockade so it comes like this:

Molecule   penetration   Virologic risk
NVP           +++            +++
EFV           ++              ++
Ril.            +                +

(all meds are approved and have well enough penetration and virologic efficacy, so the above is mostly a helper to make up you mind, no much more than that). Helps understand why some weirdos like myself still opt for NVP

Hope this helps
Eric

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