What are the treatment options for Human Immunodeficiency Virus (HIV) with an unknown infection and a CD4 (Cluster of Differentiation 4) count of 99, indicating lymphopenia?

From the Guidelines

For a person with HIV infection, a CD4 count of 99 cells/mm³, and unknown duration of infection, immediate antiretroviral therapy (ART) is strongly recommended. The treatment goals should be maximal and durable suppression of viral load, restoration and preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality 1.

Initial Treatment Regimen

A preferred initial regimen would be an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), as recommended by the international antiviral society-usa panel in 2018 1.

Baseline Laboratory Tests

Before starting treatment, baseline laboratory tests should be performed including:

• HIV viral load
• Resistance testing
• Complete blood count
• Comprehensive metabolic panel
• Hepatitis B and C screening
• Tests for other sexually transmitted infections

Prophylaxis Against Opportunistic Infections

With a CD4 count below 100, prophylaxis against opportunistic infections is also needed, specifically:

• Trimethoprim-sulfamethoxazole (one double-strength tablet daily) to prevent Pneumocystis pneumonia and toxoplasmosis

Importance of Rapid Viral Suppression

The low CD4 count indicates advanced HIV disease with significant immune suppression, making rapid viral suppression crucial. Most patients will see significant immune recovery within 3-6 months of starting effective ART, with CD4 counts increasing and risk of opportunistic infections decreasing.

Monitoring and Regimen Switch

If a regimen switch is indicated, treatment history, tolerability, adherence, and drug resistance history should first be assessed; 2 or 3 active drugs are recommended for a new regimen 1. Regular monitoring of CD4 cell count, HIV RNA level, genotype, and other laboratory tests for general health and co-infections are recommended at specified points before and during ART.

From the FDA Drug Label

Table 20 Outcomes of Randomized Treatment at Week 48 and 144 (Trial 903) ... Table 21 Outcomes of Randomized Treatment at Week 48 and 144 (Trial 934) ...

The treatment options for Human Immunodeficiency Virus (HIV) with an unknown infection and a CD4 count of 99 are:

• Tenofovir disoproxil fumarate in combination with other antiretroviral agents, such as lamivudine (3TC) and efavirenz (EFV), or emtricitabine (FTC) and EFV.
• The goal of treatment is to achieve and maintain HIV-1 RNA <400 copies/mL and increase CD4+ cell count.
• Treatment outcomes, such as virologic failure, rebound, and discontinued due to adverse event, should be monitored and managed accordingly 2. Key points to consider:
• CD4+ cell count: The mean baseline CD4+ cell count in the trials was higher than 200 cells/mm3, but some subjects had CD4+ cell counts <200 cells/mm3.
• HIV-1 RNA: The median baseline plasma HIV-1 RNA was high, but the treatment goal is to achieve and maintain HIV-1 RNA <400 copies/mL.
• Treatment regimen: The choice of treatment regimen should be based on the individual patient's needs and medical history.

From the Research

Treatment Options for HIV with Unknown Infection and Low CD4 Count

• The patient's CD4 count of 99 indicates lymphopenia, which requires immediate attention and treatment.
• According to the study 3, antiretroviral therapy (ART) is recommended for all people living with HIV to suppress viral load and stop the progression and transmission of HIV-1.
• The study 3 suggests that a fixed-dose combination of tenofovir alafenamide/emtricitabine/rilpivirine (TAF/FTC/RPV) can be used as an initial regimen for people living with HIV, but it is recommended for patients with a CD4 cell count > 200 cells/mm3.
• However, the study 4 reports a case of a patient with persistent lymphopenia despite an undetectable viral load, who improved after switching from tenofovir to abacavir, suggesting that alternative treatments may be considered for patients with low CD4 counts.
• The studies 5 and 6 evaluate the efficacy and safety of efavirenz 400 mg daily versus 600 mg daily, and suggest that the lower dose of efavirenz is non-inferior to the standard dose, with fewer adverse events.
• The study 7 evaluates the efficacy and safety of darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) in a rapid-initiation model of care, and reports high treatment satisfaction and few adverse events, but does not specifically address patients with low CD4 counts.

Considerations for Treatment

• The choice of treatment should be based on the patient's individual needs and medical history.
• The studies 3, 5, 6, and 7 suggest that ART regimens containing tenofovir, emtricitabine, and either rilpivirine or efavirenz may be effective for treating HIV, but the optimal regimen for a patient with a CD4 count of 99 is unclear.
• The study 4 highlights the importance of monitoring CD4 counts and adjusting treatment as needed to ensure optimal immune reconstitution.