Reprinted from British Medical Journal Online “AIDS Debate,” August 2003
Can We Really Count on T Cells?
By Toni Watson
 
“The doctor said her CD4 count from five years before had been 26. My friend was extremely upset at hearing this news, despite the fact that she had remained in good health for the more than five years since that count was taken. Seven years later, she is still in good health.”
 
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In Christopher Tyler’s letter (Liver Deaths and HAART - The Truth 28 July 2003), he gives several examples of the dilemmas that face individuals who have been recently diagnosed HIV positive as well as an example of someone whose health has suffered while taking the anti-retrovirals (ARVs). Although Brian Foley and others may be tempted to dismiss these examples as pure anecdote, in my opinion they serve an important purpose as they exemplify the prevailing attitude of HIV doctors, as well as how the immutable belief that a HIV diagnosis means certain death affects those who have been recently diagnosed HIV positive.
 
At the risk of attracting (for a second time) some of the rancor that Christopher Tyler’s post will no doubt receive, I would also like to offer the readers a brief personal anecdote concerning a friend of mine.
 
This person, now in her late 30s, had been an IV-drug user in her teens, eventually “cleaning up” completely in 1983. She tested HIV positive a couple of years later, but as there were no other possible means of transmission post-IV-drug-use, she dates her “infection” sometime prior to 1983. She declined to participate in any anti-HIV drug trials having seen friends who went on AZT, rapidly become ill and die.
 
During the 1990s she became involved in various complementary therapies, but continued to have routine blood monitoring, as there was considerable pressure for her to do so from her HIV-specialist doctor. She was also continually encouraged to take part in whatever current drug trials were running at the time but always declined. In 1996 she decided that the anxiety and stress caused by attending the clinic to have her blood monitored and worrying about what the results might be, was itself damaging her health. She told her doctor that she no longer wanted her blood monitored and asked not to be told the results from her recent blood counts – this proved to be a timely decision.
 
Five years later, she saw the same doctor again after contracting a minor ear infection. During the course of her consultation the doctor (despite having been asked not to) told her that her previous CD4 count had been 26. As the readers may imagine, my friend was extremely upset and frightened at hearing this news. The doctor again tried to persuade her to start the ARVs, despite the fact that she had remained in good health for the more than five years since that count of 26 had been carried out. Instead she went to see a counselor who reminded her that she was as healthy the day after having been told her CD4 count had been 26 (five years previously), as she was the day before hearing the news. She declined the offer to go on combination therapy and 18 months later, remains in good health – nearly seven years after her blood counts indicated she had AIDS (according to the CDC definition) and more than 20 years after becoming “infected.”
 
Of course my friend’s experience raises many issues about the utility of counting CD4 lymphocytes, but more importantly it illustrates the inherent danger of adopting an overly narrow viewpoint towards how and why illness manifests itself.
 
Surrogate markers may be the best tools that clinicians currently have of assessing the progress of HIV, but should they be reasons for initiating therapy in the absence of clinical symptoms? As Peter Flegg has pointed out, the risk/benefit calculation in asymptomatic individuals is clearly weighted in favor of delaying initiation of treatment, but is it (as he believes) so clearly in favor of commencing treatments when the only indicator is a low CD4 count?
 
Toni Watson <toni@watson1860.freeserve.co.uk>

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