What is the treatment for a patient with a severely impaired immune system, as indicated by a CD4 (Cluster of Differentiation 4) count of 5?

Treatment for CD4 Count of 5 cells/mm³

Immediate initiation of antiretroviral therapy (ART) is mandatory for a patient with a CD4 count of 5 cells/mm³, as this represents severe immunosuppression with extremely high mortality risk without treatment. 1

Immediate Actions Required

Start ART Without Delay

• Begin combination antiretroviral therapy immediately upon diagnosis, regardless of symptoms or viral load 1
• The evidence demonstrates a cascade of mortality associated with lower CD4 status, with clinical progression rates increasing rapidly at CD4 counts below 200 cells/mm³ 1
• For patients with CD4 counts below 350 cells/mm³, randomized trial evidence shows significant mortality reductions with ART initiation 1
• At a CD4 count of 5 cells/mm³, the patient is at immediate risk for life-threatening opportunistic infections and death without treatment 1

Preferred ART Regimens

• Modern combination therapy should include an integrase inhibitor-based regimen when possible (such as dolutegravir, raltegravir, or elvitegravir) combined with two nucleoside reverse transcriptase inhibitors 1
• Fixed-dose combinations improve adherence and are preferred globally 1
• Tenofovir disoproxil fumarate combined with emtricitabine or lamivudine plus efavirenz has demonstrated efficacy even in patients with baseline CD4 counts as low as 2-3 cells/mm³ 2

Critical Prophylaxis Requirements

Mandatory Opportunistic Infection Prophylaxis

• Pneumocystis jirovecii pneumonia (PCP) prophylaxis is absolutely required at CD4 <200 cells/mm³ and is critical at a count of 5 1
• This prophylaxis also provides protection against toxoplasmosis and some bacterial infections 1
• Antiviral prophylaxis with acyclovir or valacyclovir is strongly recommended for patients with history of herpes simplex virus or varicella zoster virus, and should be considered even without prior history at this CD4 level 1

Additional Monitoring and Prophylaxis

• Cytomegalovirus monitoring is warranted when CD4 counts are below 100 cells/mm³ 1
• Consider antifungal prophylaxis with fluconazole given the severe immunosuppression (CD4 <100 cells/mm³), particularly if mucositis is anticipated 1
• Screen for and treat latent tuberculosis, as TB risk is substantially elevated at this CD4 level 1

Baseline Evaluation Before or Concurrent with Treatment

Essential Laboratory Testing

• Complete blood count and chemistry profile 1
• Baseline CD4 count with percentage (already obtained) and repeat measurement to establish trend 1
• Plasma HIV RNA viral load measurement 1
• Hepatitis B and C serology (critical for ART selection and co-infection management) 1
• Toxoplasma IgG serology 1
• Tuberculin skin test or interferon-gamma release assay 1
• Pregnancy test if applicable 1

Clinical Assessment

• Careful oropharyngeal examination for candidiasis, oral hairy leukoplakia, or Kaposi sarcoma 1
• Comprehensive evaluation for occult opportunistic infections 1
• Assessment for HIV-associated nephropathy and other organ dysfunction 1

Special Considerations at CD4 Count of 5

Timing with Opportunistic Infections

• If active tuberculosis is present: Start ART within 2 weeks of TB treatment initiation, as this reduces mortality in patients with CD4 <50 cells/mm³ 3, 4
• Exception for CNS infections: If tuberculous meningitis or cryptococcal meningitis is present, delay ART initiation as immediate ART is associated with higher mortality in these specific conditions 4
• For other opportunistic infections (PCP, bacterial infections): Start ART within the first 2 weeks of treatment for the opportunistic infection 4

Expected Outcomes

• Mean CD4 increase after 48 weeks of effective ART in patients starting with very low CD4 counts (including those with baseline counts of 2-3 cells/mm³) ranges from 190-280 cells/mm³ 2
• The incidence of new AIDS-defining diseases/death decreases substantially once CD4 count rises above 200 cells/mm³ with treatment 5
• Immune reconstitution inflammatory syndrome (IRIS) risk is elevated when starting ART at very low CD4 counts, but the mortality benefit of early treatment outweighs this risk 3

Critical Pitfalls to Avoid

• Never delay ART initiation while waiting for complete baseline testing in a patient with CD4 count of 5—this is a medical emergency 1
• Do not defer treatment due to concerns about adherence; the mortality risk without treatment far exceeds any adherence concerns 1
• Ensure careful evaluation for drug-drug interactions, particularly with opportunistic infection prophylaxis medications 1
• Do not start ART immediately if cryptococcal or tuberculous meningitis is present without specialist consultation 4