MEDizzy - A patient with HIV infection who is receiving retroviral

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Human Retroviral Infections

A patient with HIV infection who is receiving retroviral therapy presents to you for the first time after being relocated by his employer. He has had HIV infection for 12 years; his first viral load was 100,000 copies/ml of plasma. He currently has a CD4+ T cell count of 400 cells/µl and a viral load of 10,000 copies/ml. He states that he has not missed a single dose of his medication. Which of the following statements is true regarding this patient's CD4+ T cell count, viral load, and prognosis?

ExplanationThe magnitude of HIV-1 replication in infected persons is directly associated with the rate of disease progression. This quasi–steady-state has been referred to as the viral set point. Importantly, the predictive value of high plasma viral RNA levels decreases over time, while the predictive values of low CD4+ T cell counts and CD4+ T cell function increase over time. In late stages of disease, immune deficiency is most predictive of disease progression. The relative clinical benefit of any given decline in viral RNA does not depend on the baseline viral RNA level, but the absolute risk of progression to clinical disease remains higher in the patient with higher pretherapy plasma viral RNA levels. The goal of therapy is a durable reduction in the plasma viral RNA level by at least threefold or more from pretherapy levels, to below 1,000 copies/ml, and, preferably, to an undetectable level, which is now 50 RNA copies/ml of plasma. A suboptimal response or therapeutic failure can be defined as a failure of the plasma viral RNA level to decline by at least 30-fold or more from baseline after 4 to 8 weeks. Many clinicians also consider the inability to achieve undetectable plasma viral RNA levels by 12 to 24 weeks as evidence of therapeutic failure. In as many as 15% of patients who receive antiretroviral therapy, the plasma viral RNA level increases while the CD4+ T cell count remains stable or continues to rise in response to therapy. At this time, if the increase in plasma viral RNA is either less than 0.5 log10 or 5,000 copies/ml, whichever is less, in a patient with an improved CD4+ T cell count, serious consideration should be given to continuing the same treatment regimen and monitoring the patient's CD4+ T cell count closely for deterioration.