Q and A


My CD4 count is very low, will treatment still work?

I recently found out my CD4 count is 4. I feel fine I only started having skin problems recently. I’m starting with ARVs soon but Im afraid they will kill me as I believe my body is not strong enough. Can treatment really work when you have a CD4 count this low?


HI treatment (ART) can work at any CD4 count, even when the count has become very low.

In your case, because your CD4 count is only 4 it is very important that you start ART quickly. This is because your immune system is very weak and you are at risk of developing infections like TB or pneumonia.

ART is very effective, even with very low CD4 counts. After starting treatment your CD4 count should increase to safer levels.

More than 1 in 4 (25-50%) of people with a CD4 count below 50 cells/mm3 when they begin ART get symptoms of IRIS (Immune Reconstitution Inflammatory Syndrome).

IRIS is when the immune system reacts to infections that is was previously too weak to respond to. This can cause infections like TB and CMV to flare up and need treatment. While IRIS can make things a little more complicated, it is usually easy to treat. This article from thebody.com has information on IRIS.

Although it is normal to worry about starting ART it is very important that you don’t delay. The longer you wait to start, the higher the risk of serious HIV-related illnesses.

Please let me know if you have any questions.

This answer was updated in January 2016 from a question first posted on 21 January 2013.


  1. Lisa Thorley

    Hi Prajwal,

    In response to your Q’s.
    1- People are at risk if they have a low CD4 count and they aren’t on medication. As long as someone is on medication, then the chances of them getting ill are much less.
    2- CD4 counts rise differently from person to person. Therefore it isn’t possible to predict how long it will take to rise and to what level. The important thing is to be on medication.
    3- The medication that you’ve been given is for precaution. It’s unlikely that you’ll get any OI because you’re on medication.

  2. Prajwal

    Hello Roy,

    Thank you for the response. I have few questions running in my mind and it would be great if you could help me understand facts about the below mentioned points

    1. What is the relation between mortality and ART in the first year. Who is at risk ? What CD4 range is associated to mortality ?

    2. How much time does it take for the CD4 to come up? My CD4 count before ART was 241 and I’m on ART since 5 weeks now..

    3. What opportunistic infections should I be aware of for my CD4 count ? Though my CD4 is above 200 my doctor has advised me to take Bactrim DS to prevent pneumonia and other infections.

  3. Roy Trevelion

    Hi Prajwal,

    I’m sorry to hear about your recent diagnosis. But it’s good that you’ve started ART.

    IRIS (immune reconstitution inflammatory syndrome) is illnesses that occur when HIV treatment is started when the CD4 count is very low. IRIS occurs because the immune system quickly becomes stronger and identifies infections that it was previously too weak to fight.

    For example, IRIS can occur in 1 in 4 (25%) people who start with a CD4 count under 50. But your CD4 count is stronger, it’s less likely to occur with a CD4 count of 241.

    Although the symtoms are serious, IRIS can usually be easily managed.

    Here’s the Introduction to ART for more information.

  4. Prajwal


    I found that I am HIV positive almost a month ago and my CD4 count was 241. I started ART after 3 days and it’s been 20 days now. My question is will I develop IRIS for my CD4 level ?

  5. Roy Trevelion

    Hi Sonny,
    Thanks for getting back to us after talking to your doctor.

  6. Sonny

    Regarding why doctor hasn’t give me Cotrimoxsazol is below. On her knowledge cotrimoxsazol is prescribed to a patient with CD4 lower than 200 to avoid Pneumonia and Toxoplasma
    On my case, because when i was diagnosed HIV+, my doctors already knew that Im also having Toxoplasmosis Cerebral from my first MRI result.
    The consideration she took at the time, she chose to prescribed me with Clindamicyne because it has a better loading Doze 4 x 600mg with minimal side effect than what the cotrimoxsazol has.
    Thanks Lisa

  7. Sonny

    Hi Lisa,

    Thank You for the support, God blesses me with a very kind Doctor who always reply my whatsapp everytime i have questions.
    I Whatsapp her right away, and let you know her considerations

  8. Lisa Thorley

    Hi Sonny,

    Its great to hear that you’re getting better.

    I don’t know why your doctor hasn’t given you cotrimoxsazol, as its common practice to give it to people who are positive with low CD4 counts. When are you due to see them next? Maybe you could ask them then.

    Because your CD4 is low, you may find this link helpful:


  9. Sonny

    Hi i-base

    Im Sonny, my doctor diagnosed me with HIV + on March 12, my CD4 is 9 and I also have Toxoplasma Cerebral, ive been on Toxoplasmosis medication (Pirimetamin and Clyndamicine) for these last 1,5 months because my doctor said that the acute periode for the Toxoplasmosis is 6 weeks, last MRI check my Toxoplasmosis is getting better, she said the edema perifocal that used to be on my brain is nearly gone, but i still have the lesions that needs to be treated.
    Once i have my result for being HIV + my doctor told me to also star to use ARV (Tenovovir, Efavirenz and Lamivudin)

    I still have one big question on my mind why my doctor didnt suggest me to consume cotrimoxsazol.
    Is there any consideration she took why she didnt also give me cotrimoxsazol at the beginning of my treatment?

  10. Lisa Thorley

    Hi Sifiso,

    Your question has been answered here: http://i-base.info/qa/4797


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