What treatment is recommended for a patient with a low CD4 (Cluster of Differentiation 4) count and percentage, indicating a compromised immune system?

Treatment for Low CD4 Count (264 cells/μL)

Antiretroviral therapy (ART) should be initiated immediately for this patient with a CD4 count of 264 cells/μL to prevent disease progression, reduce mortality risk, and improve immune function. 1

Assessment of Immune Status

The patient's laboratory results show:

• CD4 absolute count: 264 cells/μL (below normal range of 490-1740)
• CD4 percentage: 14.77% (below normal range of 30-61%)
• CD8 absolute count: 961 cells/μL (normal)
• CD8 percentage: 53.76% (above upper limits)
• CD4/CD8 ratio: 0.27 (low)
• Absolute lymphocyte count: 1787 cells/μL (normal)

These values indicate significant immune dysfunction with selective depletion of CD4+ T cells, consistent with HIV infection.

Treatment Recommendations

When to Start ART

ART should be initiated immediately based on current guidelines that recommend treatment for all HIV-infected individuals regardless of CD4 count 1. The urgency is particularly high for this patient because:

1. CD4 count <350 cells/μL significantly increases risk of disease progression 1
2. CD4 percentage <15% indicates severe immunosuppression
3. Low CD4/CD8 ratio (0.27) is associated with increased risk of non-AIDS morbidity

Recommended Initial Regimen

For most patients, including those with low CD4 counts, the following regimens are recommended (in alphabetical order) 1:

• First-line options:
  • Bictegravir/tenofovir alafenamide (TAF)/emtricitabine
  • Dolutegravir/abacavir/lamivudine
  • Dolutegravir plus TAF/emtricitabine

These integrase inhibitor-based regimens are preferred due to:

• High efficacy in achieving viral suppression
• Good tolerability profile
• High barrier to resistance
• Once-daily dosing

Alternative Regimens

If first-line regimens are not available or appropriate, the following alternatives can be considered 1:

• Darunavir/cobicistat plus TAF (or TDF)/emtricitabine
• Darunavir boosted with ritonavir plus TAF (or TDF)/emtricitabine
• Efavirenz/TDF/emtricitabine
• Elvitegravir/cobicistat/TAF (or TDF)/emtricitabine
• Raltegravir plus TAF (or TDF)/emtricitabine

Expected Outcomes and Monitoring

CD4 Response to Treatment

With effective ART, most patients experience significant CD4 count increases, but the magnitude varies:

• Poor CD4 recovery (<50 cells/μL increase after 8 months of effective ART) occurs in approximately 18% of patients and is associated with:

  • Older age
  • Lower baseline viral load
  • Not with baseline CD4 count 2

• Patients with poor CD4 recovery have higher rates of both AIDS and non-AIDS events (5.8 vs 2.7 per 100 person-years) 2

Monitoring Parameters

1. Viral load: Check at 4-8 weeks after ART initiation, then every 3 months until consistently suppressed
2. CD4 count: Monitor every 3-6 months initially, then less frequently once stable
3. Assessment for opportunistic infections
4. Medication adherence evaluation at each visit

Special Considerations

Opportunistic Infection Prophylaxis

Since the CD4 count is >200 cells/μL, primary Pneumocystis pneumonia prophylaxis is not indicated at this time 1. However, close monitoring is essential as the patient's CD4 count is near the threshold.

Potential Complications

1. Immune Reconstitution Inflammatory Syndrome (IRIS): More common in patients with lower CD4 counts starting ART
2. Suboptimal Immune Recovery: About 7.7% of patients with pre-treatment CD4 <200 cells/μL fail to achieve CD4 >200 cells/μL after 3 years of effective ART 3
3. Medication side effects: Vary by regimen selected

Pitfalls to Avoid

1. Delaying ART initiation: Historical guidelines recommended waiting until CD4 counts fell below certain thresholds, but current evidence strongly supports immediate treatment regardless of CD4 count 1

2. Inadequate adherence support: Poor adherence leads to treatment failure and resistance development

3. Overlooking drug interactions: Carefully review all medications the patient is taking before selecting an ART regimen

4. Ignoring comorbidities: Renal function, hepatic status, cardiovascular risk, and bone health should be assessed when selecting a regimen

5. Failure to address psychosocial barriers: Housing instability, mental health issues, and substance use can impact treatment success

By initiating ART promptly with an appropriate regimen, most patients can achieve viral suppression and immune reconstitution, significantly reducing morbidity and mortality associated with HIV infection.