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Simon Collins, HIV i-Base

Treatment Q & A’s

The i-Base website lets you email questions that are then answered online. All information in anonymised, and you can also have questions answered personally without going online.
www.i-Base.info

Question
Should I stop using abacavir if I am worried about a heart attack?

Answer
This is a big subject – given that abacavir is currently one of the most widely prescribed drugs. The question has only become important because of recent findings from the D:A:D study presented at the Retrovirus conference in February and published in the Lancet medical journal in April.

Use of abacavir, whether you are already on treatment or starting for the first time, depends on two important factors: i) your current risk of having a heart attack, and ii) your alternative treatment options.
The D:A:D study found abacavir was associated with an increased risk of heart attack, but that this was most significant in patients who had a high underlying risk of heart disease.

Your risk of having a heart attack is estimated by your doctor putting a few of your lab results into an online risk calculator (usually Framingham). Results are shown as low, intermediate or high risk of a heart attack in the next 5 or 10 years.

Secondly, even if this risk is high, you need to have an alternative drug to switch to. This will depend on your previous treatment history.

Within a few weeks of the initial HIV infection, viral load shoots up and the CD4 count goes down. As the body fights the infection, it usually is able to bring the viral load back down.”

For people with highest risk, and who have other options, then switching is probably a good idea.

Everything in HIV has to be individualised to your specific health and treatment history. This is something to talk about with your doctor. Please do not stop abacavir without your doctor’s knowledge and support. The absolute risk of heart disease is still generally low for most people and your HIV combination needs to keep HIV under control.

The link between abacavir and an increased risk of heart attack in the D:A:D study was new and unexpected. Many doctors are interpreting the results cautiously until the findings are supported by other research groups.

The Position Statement from the D:A:D researchers includes a Q&A section about what this means and is worth reading for more detailed answers www.cphiv.dk.

Question
Can I find out when I was infected…
Does a CD4 count of 690 and a viral load of 19,000 mean I have only just caught HIV of have been positive for 5-10 years?

Answer
With only one set of test results, either option could be true - or any number of other possibilities.

One set of results doesn’t tell you much. Most importantly, it doesn’t tell you which direction the counts are going in (increasing, decreasing or are stable), or how quickly anything is changing.
Usually you need 3-4 sets of results over a year before you can use the results to guess at when you might have been infected.
This will only ever be a guess though, and you will never know for sure. Sometimes if you remember seroconversion symptoms - a week or two of heavy flu - this can help with the possible time.

Question
What are the chances that CD4 could go up without treatment?
I was recently infected and my CD4 count is 200 and viral load is 100,000/ Could my CD4 still rise on its own?

Answer
We need to know what you mean by ‘recent’ to properly address your question.

Different people use recent infection to mean anything from a few weeks to over a year. Within that period of time there is a lot that can go on with your CD4 count as well as the viral load.

Usually, within a few weeks of the initial HIV infection, viral load shoots up (often into millions of copies/mL) and the CD4 count goes down. As the body fights the infection, it usually is able to bring the viral load back down. The CD4 count rebounds higher again, but not usually to quite as high as it was originally.

If you are still in this very early period, then your count could still increase.

If your infection was over a year ago, it is likely this is a real indication of the effect of HIV and you may need to consider starting treatment.

Athough guidelines recommend treatment before your count falls below 200, this isn’t the same in recent infection, if you do not want to start treatment immediately. As long as your CD4 count is generally stable, you have time to get other blood results (preferably one each month) to inform this decision.

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