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Updated July 15, 2011

Case 5: Discordant CD4 Cell Count and Viral Load Responses to Antiretroviral Therapy

Author: David H. Spach, MD

A 42-year-old HIV-infected woman with a CD4 count of 36 cells/mm3 and an HIV RNA level of 126,000 copies/ml is newly diagnosed with HIV. She starts on daily trimethoprim-sulfamethoxazole (Bactrim, Septra) and weekly azithromycin (Zithromax) followed 3 weeks later with tenofovir-emtricitabine (Truvada), atazanavir (Reyataz), and ritonavir (Norvir). Within 16 weeks, she has an HIV RNA level less than 50 copies/ml and she maintains an undetectable HIV RNA during the next 3 years of antiretroviral therapy. Her CD4 cell count, however, does not increase significantly, remaining in the 110-130 cells/mm3 range. She is tolerating her medications without any difficulty.

What would you recommend in this setting?

A Give subcutaneous interleukin-2 twice daily for 5 consecutive days every 8 weeks until the CD4 count is greater than 200 cells/mm3.
B Switch the atazanavir plus ritonavir to lopinavir-ritonavir (Kaletra).
C Discontinue antiretroviral therapy, since it appears the patient has not had a good CD4 cell count recovery.
D Continue the current antiretroviral regimen and Pneumocystis prophylaxis, but discontinue azithromycin.