Less Cd4 Counts Needed

A recent article by a major HIV thought leader, Paul Sax, MD from Harvard, reminds providers that we should only perform a test if it will cause an action. If I have a headache that is relieved with Tylenol™, I shouldn’t get an MRI scan of the head since it will not help me and may incorrectly find something that causes me to have brain surgery for nothing. Yes, tests can be wrong. Mammograms and PSAs find many things wrong that will not hurt the patient. But to be sure, many times a biopsy or surgery is performed causing much stress and some suffering for no good reason.

Antiretrovirals lower viral load, they do not affect the CD4 count. So if you are on medicine and stable, then noting those CD4s every few months is not helpful when your viral load is quite low or undetectable. They are interesting to watch but do not result in a change in therapy. Of course if we are watching for your CD4 to rise past the level where we can stop or start your prophylactic antibiotics or antiretrovirals, then that is helpful. I realize this will be a habit that will be hard to let go of. For my public health clinic, the state requires the CD4s.

Crofelemer is now approved by the FDA for diarrhea caused by antiretrovirals. It was a little better than placebo. If an HIV patient has diarrhea, a provider usually asks questions and tests the stool to see if it is caused by an infection so proper treatment can be started. If no cause is found and the antiretrovirals are suspected, I usually prescribe Lomotil™ or Imodium™. If those don’t work, I might consider this new medication if it is paid for by the insurance.

An integrase inhibitor, raltegravir, had better levels of many chemicals associated with cardiovascular disease compared to protease inhibitors. Of course we would like to see if it result in less heart attacks and strokes but this will take years to find out. The other integrase inhibitor available, elvitegravir, is in Stribild™ and we cannot assume it has the same heart friendliness.

This has been observed so some sites are using the ORAQUICK blood test only. False positive tests are more common in pregnancies, many, many diseases including a recent viral infection, and with having a recent vaccination. This new study found that type O negative blood and having an HIV positive sex partner caused more false positives. The HIV positive partner may be transmitting antibodies or ineffective HIV (like a vaccine) to the negative partner without truly causing full HIV transmission.

A study from Philadelphia showed that those HIV patients who received a quadruple dose of flu vaccine had great antibody protection compared to those who received the standard dose. This study hasn’t shown that there is less flu in those receiving the higher dose; this would be the next study to perform. We will wait till the HIV guidelines are updated to enact this since only one study found this so far and doing this would be expensive.

A recently published Danish study showed that HIV positive smokers lived 12 years less than non-smokers and may have a 4-fold risk of dying compared with HIV positive non-smokers. More than 60% of the deaths in the HIV patients were related to smoking. Those who smoked as little as once a week were considered smokers. Injection drug users were not included (probably since they already have a high risk of early death). The years lost from smoking were far greater than the few years lost due to having HIV. These were patients with access to good care and free antiretrovirals. Of course there will be a range of patient types: some not on antivirals who should be, heavy and light smokers, but this study gives you the average difference.

This study underscores the importance of paying close attention to the health problems HIV patients have apart from their HIV.

Heavy smokers (30 or more cigarettes a day) had 4 times greater risk of dying vs. light smokers (less than 30). Heavy smokers had 7.5 times greater risk of dying than non-smokers. Previous smokers had less chance of dying compared to current smokers so quitting was quite helpful.

You know smoking is bad. Make a plan to stop. Set a date. Execute your plan. Revise your plan if there are problems. 1-800-NO-BUTTS or 1-800-45-NO-FUME can help you make a plan and help you revise your plan. Talk all you want about other health issues you have but this is the BIG ONE you should be paying attention to.

Keep those questions coming. Be Safe!

Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside
HIV Researcher, Desert AIDS Project

References: Medscape