Question
Feeling tired on Atripla/Sustiva and CD4 increases after restarting treatment
5 June 2008. Related: All topics, CD4 and viral load, Newly diagnosed, Side effects, Starting treatment.
I was diagnosed in Feb 2005 when I was only 19.
My viral load was quite high and my CD4 dropped quite rapidly over a year, and I then started on efavirenz (Sustiva) and abacavir+3TC (Kivexa) and my CD4 rose to 300 and my viral load became undetectable. Unfortunately I caught hepatitis C in 2007 and my HIV treatment was stopped. My viral load shot back up over 2 months and I was then started on Truvada (tenofovir+FTC) and Sustiva. My viral load went back down to undetectable and my CD4 was on average around 300-320.
Luckily my liver cleared the hep C on its own and I didn’t need treatment for that. My CD4 has always stayed around 300-320.
Two months ago, as I was stable, it was decided to switch me to Atripla.
The question I’m asking is why isn’t my CD4 rising, but yet my viral load is undectectable? I generally feel tired all the time and not very well. Does this mean I may have AIDS?
My consultant tends not to tell me much as he knows I worry a lot about my health. Is Atripla quite a good anti-hiv drug?
Answer
Hi
Thanks for your question and the chance to answer online so other people can see the information. Your question is I am sured shared by others.
It would be useful to know what your viral load was when you were diagnosed. I will assume by ‘quite high’ that you mean over 100,000 copies/mL but I understand that it could be anywhere within a wider range. The same for your CD4 counts.
This would help know whether it was likely that this was still a recent infection – also possible because of your age – and therefore whether your falling CD4 count was related to still being in seroconversion (ie before your body generated it’s own immune response).
Either way, it is great that you responded well to the HIV treatment. You are also very lucky that you were able to clear hepatitis C without treatment. I know this is an increasing worry in the UK, and your life will be much easier without the complications of managing two infections. Although your cleared hepC once this doesn’t give you protection from reinfection with HepC in the future – so please be careful to take appropriate protection there.
Now you have restarted treatment, it is good that your viral load went back to undetectable levels. CD4 count changes though are generally much less dramatic and take longer to respond. As your count is over 200 cells/mm3 you are unlikely to have any AIDS-related complications, and as your count is over 300, then this risk is even lower.
Because of this – ie that you are out of the risky zone – then I wouldn’t worry much more about your CD4 count – so long as it stays stable and doesn’t drop significantly.
You may continue to see gradual increases over the next year or two – or it may be that your natural CD4 level is low anyway. On this last point, you will never know this (because you don’t have a CD4 count from before you caught HIV), but even if this is the case, it shouldn’t have any impact on your long term health.
I’m more concerned about you feeling tired and not well. Without more details, and because your CD4 count is good, I would probably think that this is more likely to be related to side effects than to HIV/AIDS.
Efavirenz (Sustiva) is a great drug fro bringing down viral load, but the side effects can vary considerably between different people, and also include side effects that can change your mood and energy levels. This is particularly important if your sleep is affected. ie if you still dream vividly, or have interrupted sleep, then the change in sleep with have an impact on your energy levels and how you feel the next day.
If your routine monitoring tests (ie for liver and kidney function, and red blood count for anaemia etc) are all fine, and your doctor can’t suggest an alternative explanation, then you could consider switching the efavirenz for a different HIV med.
This is easy and safe, and is the only way you can find out if this is the problem. It will involve taking slightly more pills each day (because Atripla is the only combination with 3 drugs in one, once-daily pill) – but your day-to-day quality of life might be much better.
Info on these Sustiva side effects is at this link.
There are several alternative drugs to switch to including nevirapine, atazanavir/r and lopinvavir/r. Atazanavir/r (Reyataz+ritonavir) is a once-daily drug and is often the preferred withc for people who have problems with efavirenz. There are advantages and disadvantages of the other options, both of whihc may be safe to use as once-daily treatments, once your viral load is confirmed as staying undetectable for the first month or two after the switch.
Alternative treatment may even have a different effect on your CD4 count, though this would be more to chance than because we have seen this in any studies.
Finally, it would be useful to know where you are treated, whether everything else is ok now, and how you are doing.
If it is useful to discuss any of this, then please give the phoneline a call.
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