When to start antiretroviral therapy_?
 
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Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai.

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056. India.


Clinical Problem :
An 8 years old HIV infected boy was referred for further management. At the age of 6 years, he was diagnosed to have Immune Thrombocytopenic Purpura {ITP} with platelet count of 8000, cumm and purpura. He was treated with platelet transfusions, whole blood and steroids after which his platelet counts were normal. There was no other illness in past. Both parents were HIV negative. On examination, there were no abnormalities. Investigations showed positive Western blot for HIV-1. His serial CD4 counts are depicted in Table 1. His HBsAg and Anti HCV ELISA are negative. He continues to be asymptomatic.


Question :
When should he be started on antiretroviral therapy_?

Expert Opinion :
This child has a decreasing CD4 count trend. Thus it appears that his immunity is waning. However, his Cd4: Cd8 ratio is fine, suggesting that the HIV virus is not actively replicating. Thus, one wonders as the cause of his decreasing CD4. Since the child’s WBC count is also low, the absolute CD4 count may appear low. Thus in this child there is relative CD4 cytopenia and not an actual drop in CD counts. Infact his CD percent appears to be normal. Thus this CD4 trend does not depict an immunosuppression. Infact his CD4 count at the age of 12 years again was 577 {36.4 percent} and CD4:CD8 ration was 1.61. Thus in this child one would not start ART currently.

E-published: June 2010 Vol 7 Issue 6 Art No. 36


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