Question

Questions about test results if recently diagnosed

6 December 2008. Related: All topics, CD4 and viral load, Newly diagnosed, Starting treatment.

I wanted to ask a couple of questions. I have been positive less than a year. I had an initial viral load of 22,000 and CD4 of 301. The follow-up immediately thereafter showed a CD4 of 396. I am not taking HIV medications. My blood test 3 months after the first two blood test showed a CD4 of 342, but a reduction in viral load to 6000. After that, I made several changes to my nutrional routine, added more exercise, and curtailed my smoking. I am 35 years old and in excellent health. Two months after the 2nd round of blood tests my recent blood test yielded a CD4 of 462 and a viral load of 6000. I am not taking medications.

I know that some cd4 variance is to be expected based on lifestyle factors and time measured.

Are some people able to improve their cd4 counts without HAART?

My doctor says that viral load is not clinically significant, but rather just a measure of contagion or ability to pass the virus to others. Do you agree?

Do elite controllers and those with some natural ability to control the virus always start out with ‘good numbers’; or is there documentation of people achieving some viral supression and improved CD4 counts without treatment with HAART?

Answer

Answer: Simon Collins

Thanks for your questions which I’ll try to cover in the same order after this general info.

In the first year or so after infection there is a large variability in individual responses. In the first weeks, viral load can easily be several million copies/mL and your CD4 count takes a drop. Then your immune system kicks in and starts to fight back.

Viral load then drops much lower to what is called a viral set-point, and the CD4 count usually recovers, though not to pre-infection levels. The ‘viral set-point’ is a nice idea – and works well looking at average figures for large groups of people, but is more difficult to use on an individual basis, other than as a general idea.

This is because, for some people, viral load drop quickly but for others this still goes down over the whole year. With only a few tests a year you will never know when you have reached the lowest point and when it has started to slowly rise again.

In general it is just helpful to know that most people over the first year manage to control the virus, get a CD4 recovery, and then manage to generally control HIV for the next few years without treatment.

i) On this level, nearly everyone controls HIV without HAART for several years. Lifestyle changes may help your health in many ways, but not really in terms of CD4 and viral load results – there is too much natural fluctuation. As well as the factors you mentioned, only 2% of your CD4 cells are in your blood so a relatively small temporary increase or reduction in blood can just reflect a movement of these cells rather than any real change in your immune system.

ii) Your doctor is right that CD4 count is generally the most important test result used to decide when to start treatment, but viral load could also be a factor if it is very high (over 100,000 copies/mL. Page 7 of the BHIVA guidelines includes a table where CD4 count and viral load show your risk of becoming ill in the next 6 months depending on whther or not you are on treatment or not for 3 different ages: 25, 35 and 45 years old. This is a very useful table for everyone to use as a reference.

iii) The trend above counts for everyone. There are a very small group of people who continue to have undetectable viral load viral load 10, 15, or even 20 years after infection. As this is just dependent on genetics I don’t like the term ‘elite controllers’ – though it has become used more in the last few years. Long Term Slow Progressors (LTSPs) is probably more accurate and nicer term.

One recent UK study showed that the average time after infection before starting treatment was 5 years. But 25% people needed to start earlier than two years and 25% didn’t need to start for 10 years.