This issue’s specialist:
Dennis Myers MSN, FNP, AAHIVS
Dear HIV Specialist,
I was first tested positive for HIV in July of this year. My viral load was 5,850 and my CD4 count was 470. Three weeks later my viral load was 59,800 and CD4 count was 440. I have not yet been treated for HIV. How alarmed should I be that my viral load increased significantly, but my CD4 count only changed less than 10%? Are my results at a level where I should be taking medication for HIV?
Not Panicking Yet
Dear NPY,
I would not be very alarmed at the present time. Viral loads increase for a variety of reasons including progression of HIV disease, immunizations, and other infections. It is also possible that your viral load increase represents the rising viral load that you see in the first weeks of new HIV infection. Immediately after infection, the viral load increases rapidly, peaks, and then levels off to a lower, more stable value. The first value may be prior to the initial peak.
Your CD4 cell count did not change much during the three week period because it takes a longer time for CD4 cell counts to change than viral loads. If your viral load is persistently high, then the CD4 cell count will fall, but this may take months, even years, to happen.
According to the most recently published guidelines by the Department of Health and Human Services (November 2008), your results are not at a level where it is essential for you to take therapy if you are otherwise healthy and not pregnant. The critical CD4 level for starting therapy is less than 350cells/mm3. However, multiple studies have shown that persons who start therapy at CD4 cell counts greater than 350 are more likely to achieve higher CD4 cell counts. In addition, a study published in April 2009, after the guidelines were published, showed that persons who deferred starting therapy until their CD4 cell count was less than 350 had a higher risk of death than those who started therapy immediately.
You should repeat your viral load and CD4 cell count and then seek help for any problems that you may have that would make taking medications difficult, such as drug use or mental illness. If the results are similar to the results that you have already received, I would talk to your provider about starting therapy. 
Lori Fantry, M.D., MPH, AAHIVS
Associate Professor of Medicine
Institute of Human Virology
Baltimore, MD
