Slipping Backwards 


A middle aged lady had been admitted feeling generally unwell, with a cough, systemic symptoms, and she had HIV.

This was all elicited from the history and none of it was remarkeable, but as the story unfolded tears ran down her cheeks.

I tried to comfort her, less with words than a hand on the shoulder, and she explained that she had not been on antiretroviral treatment (for HIV) for over 5 months.  This was largely due to circumstances outside her control, but she was sincerely upset at the potential state of her health after missing such crucial treatment for so long.

I took bloods for CD4 count and viral load, both of which were subsequently very poor. The CD4 was 17, and the viral load very high. One year previously, her viral load was undetectable.

Tests for TB and cryptococcal antigen (routinely tested for if CD4 counts are below a certain threshold) were both negative.  She was commenced on empirical treatment for a chest infection and referred to the medical team. 
 
 
HIV, CD4 and Viral Load
 
Within 2 -4 weeks but up to 3 months after HIV infection, primary HIV infection (also called seroconversion) can occur.  This often presents as flu like symptoms, also maculopapular rash, pharyngitis and other sexually transmitted diseases may present.

In the absence of diagnosis or treatment, the patient my remain clinically well for up to 3 years, as “latent” HIV, with a CD4 count slowly dropping.

The CD4 count can transiently drop to <200cells mm="" sup="">3
during which time the patient may be exposed to opportunistic infections e.g. PCP (Pneumocystis jiroveci – pneumonia). Antiretroviral treatment is now very effective and can maintain good quality of life and stable disease control. Poorly controlled disease will result in progressively reduced CD4 levels – normal levels being 500 – 1500 x 106 cells / mm3. Below 500 opportunistic fungal, bacterial and viral infections may present, as well as TB infection. Below 200 is technically AIDS – Acquired Immune Deficiency Syndrome, when there is susceptibility to PCP, Toxoplasma,Cryptococcus, Cryptosporidia and Kaposi sacoma. Below 100, atypical mycobacteria, CMV, aspergillus and lymphoma may occur.  
 
Viral load is a marker of response to treatment – if viral load is undetectable the person is unable to pass on the disease. 
 
 
Current guidelines from WHO recommend starting ARV treatment for anyone diagnosed with HIV – this has been shown to improve response and reduced chance of transmission. Years previously practice was to delay treatment until CD4 counts reached around 300, based on concerns over viability of long term adherence, and side effects of ARV treatment.


https://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/





































Comments











Post a Comment




















Popular posts from this blog









Anxiety and Fractures




















Image







  The little boy was sat cuddled on the lap of a young woman. I presumed she was his mother. She wasn’t.   He was about 2 and a half, a toddler.  He looked about the right size for a toddler, not undernourished and small like so many of his peers.       He seemed comfortable enough, sat sideways across her lap, she was cuddling him but didn’t make a fuss, he was equally calm, eyes half closed as I approached.   The triage sheet simply stated: “PVA” - this is “pedestrian vehicle accident”, i.e. pedestrian hit by vehicle.  He had been carried on his mother’s back when she was struck by a vehicle, I presume a car.  There was no witness from the scene, and the mother was apparently elsewhere in the emergency department being treated for her injuries – though when I searched later I  could not find any sign of her.         The child had apparently been flung some distance from the mother and landed on tarmac, this was all I could glean from the lady caring for him, she shrugged whe...








Read more










Introduction





















In 1997 I was diagnosed with Takayasu's Arteritis, a rare inflammation of the large arteries in the body: for me the aorta and carotid arteries.  The result was that over time I developed aortic regurgitation (a heart murmur)  and carotid stenosis (narrowing of my carotid arteries leading to the brain).  Despite this I have been able to pursue a career as a mountaineering instructor and outdoor educator for the past 14 years, and pursue my own mountaineering, climbing and kayaking adventures.  I recently underwent open heart surgery, replacing my aortic root and valve.  I have not been able to find much information on heart defects and their impact on activities for young, fit people such as myself, nor have I found a recovery regime for open heart surgery for young fit people.  This blog is intended to provide information on my experiences of the disease, treatment and surgery, and how I am recovering.  I hope this is of use to others who are or may be in a similar situation in th...








Read more










Arriving for surgery





















I arrived at the John Radcliffe Hospital in Oxford on Tues 19th August. Since knowing I was due to have the operation, and that I would be out of action for a few months afterwards, I had wanted to get the most from the previous months.   I had plenty of evenings and weekends rock climbing, running and cycling. Worked for a couple of weeks running mountain courses at Plas y Brenin - where Mo & I could get out climbing in the evenings and weekends too.   In July I went to the Alps for a couple of weeks with my best mate - dodging thunderstorms and doing some climbing and mountaineering.     I had made the most of the summer, and tried to ready myself psychologically for the op.     I was nervous, I won't lie. I had never had an operation before let alone a very big one like this.  The surgeon Mr M had been very good at explaining the whole process with the options to me, and answered my questions honestly, but that was in May when it all still seemed a long way off. Now it was r...








Read more