Saturday, December 7, 2013

At What CD4 Do OI's Attack?

When I was confined at the hospital for meningitis, I came across a research study published in October 2012. I have a math/science background, so I find studies showing numbers and statistics interesting. Well basically, the study states the average CD4 counts at which typical opportunistic infections (OI's) attack Filipino AIDS patients.

Legend: PTB - pulmonary tuberculosis; PCP - Pneumocystis pneumonia; ePTB -  extrapulmonary tuberculosis; dis TB - disseminated tuberculosis; othrush - oral thrush; CMV - cytomegalovirus; crypto - Cryptococcus meningitis; ethrush - esophageal thrush; toxo - toxoplasmosis). 

What This Means to Me? 

My latest CD4 count during that time was 15. That explains the reason why I had PCP, ePTB, dis TB, othrush, and crypto. These figures also explain the sequence of my infection, starting with ePTB, followed by PCP, then  crypto, since my CD4 was continuously worsening before I started my ARV. The study also says that crypto is the deadliest OI for Filipinos (16.7% die from it). On the positive side, I can say I was blessed to have survived crypto. And I was lucky not to have CMV which attacks at an average CD4 of 48 (or alternatively we can say CMV can only be obtained by PLHIV with 0-111 CD4 count, 95% of the time; or only 5% of the time is CMV obtained by PLHIV who has a CD4 count of more than 111). 

So, I started to wonder, why didn't my doctor prescribe me a prophylaxis med for CMV. I found the answer from the internet. 

"Taking oral ganciclovir or valganciclovir to prevent a first attack of CMV disease among people with low CD4 cell counts is controversial. Both valganciclovir and oral ganciclovir have been licensed in the United States, but not the United Kingdom, as primary prophylaxis against CMV, despite the limited evidence of the efficacy of this strategy. One trial reported in early 1995 found that it approximately halved the risk of developing a first episode of CMV disease among people with CD4 cell counts below 50 cells/mm3, or people with CD4 cell counts below 100 cells/mm3 who had experienced an AIDS-defining illness. However, another trial found no significant reduction in CMV disease among people taking oral ganciclovir. These conflicting conclusions may be explained by differences in the study designs, including participants' CD4 cell counts, the duration of treatment and the ways in which CMV disease was diagnosed." Also, I read somewhere that CMV prophylaxes are very expensive! So, what HIV doctors normally do is just a regular eye checkup. 

After 3 months of ARV, my CD4 increased to 91. This number means my risk of having toxo and CMV has already been reduced. Cheers to that! :)

This study also teaches me a lesson. If I only consulted an Infectious Disease Specialist (IDS) when I contracted ePTB, that IDS would have definitely asked me to take an HIV test. And that test could have started me on my ARV and prophylaxis meds (preventive meds), even before my CD4 decreased to less than 86 (which is the average CD4 at which PCP attacks). I could have potentially avoided getting PCP and crypto and saved more than Php 350,000 from hospital and medicine expenses, as well as saved me several months worth of unearned salary due to medical leave.  Hope this serves as a lesson for others who suspect that they could be HIV positive. Yes, there's no cure for HIV, but early diagnosis and treatment is a MUST. It will save you from potentially deadly opportunistic infections; it will save you from costly hospitalization, and most importantly, it will save you and your loved ones from the emotional roller coaster that you'd ride if you get Opportunistic Infection(s).   

But please... don't be misled. Follow what your doctors. If he says you

still need to take prophylaxis meds to prevent certain OI's, follow him religiously. What they prescribe are typically based on WHO's standards for the management of AIDS patients, which are based on years of statistical analyses. The figures above are just average CD4 counts, but they definitely do not say that at these CD4 counts, prophylaxis meds can be safely discontinued. Remember, preventive meds are better and cheaper than actual treatment.