Question:

There is currently much confusion in my country, South Africa, regarding the best treatment for HIV/AIDS infections. I am sure you are aware of this, esp with our minister of Health espousing certain "vegetable and herbal" cures like beetroot, potato, lemons etc. I have the following questions, which I would be grateful for some straight and clear answers. I understand that people also vary (probably greatly) in their immune responses to the virus but if in your answers you could include the "most commonly encountered windows" I would be grateful.

1. Scenario 1: a person is HIV+. At what stage of infection do the CD4 counts and VL indicate full-blown AIDS? Is there a relationship at all?
2. Scenario 2: a person with HIV/AIDS is diagnosed with an opportunistic infection like TB. Again, can this be in the HIV phase must it be AIDS?
3. What is the best treatment regimen for a person presenting with HIV/AIDS? Do you immediately begin a course of ARVs, or do you look at factors like improving diet (to get the strength up) before commencing ARVs? In other words, will a seriously weakened body react badly to ARVs?
4. Is there a stage of HIV infection (eg CD4>200, VL <10,000) at which one will simply monitor these stats, improve diet, lifestyle etc (eg exercise, sleep). Or would one ALWAYS commence ARV treatment asap?
5. Am I correct in the assertion that the 'mechanism' thru which HIV becomes AIDS is still as yet unknown? And that the purpose of most ARVs is to prolong the HIV phase as long as possible? Can it be prolonged indefinitely? Can it be reversed (back to 'just' HIV+)?
6. Is there a source of information available that one could address questions like mine (most of which I am sure are very naïve) to get answers, as in the sense of a manual?

I appreciate your time spent on this.

Answer provided by:

The only foolish question is the honest question not asked. I am glad to try to help.

I am aware of the unfortunate controversy about AIDS treatment in your country. There is no serious scientific debate in the international community: HIV causes AIDS, and antiretroviral therapy is effective therapy.

The term AIDS is older than the discovery of the Human Immunodeficiency Virus. It was used to describe a syndrome of unknown cause, and retains usefulness for epidemiology. Medically, it is less useful. and I wouldn't get too hung up on the difference between AIDS and advanced HIV infection. AIDS may be defined by opportunistic infections, or a CD4 T-cell count of less than 200. In your area, TB is often used as a marker for AIDS, in the setting of HIV.

Treatment of HIV/AIDS depends on the individual patient. In the US, guidelines suggest that antiretroviral therapy begin at around 300 CD4 cells. When people have lower T cell counts, they may have less dramatic improvements in immunity if they delay therapy. If patients have above 350 CD4 cells, and a moderate viral load, certainly 10,000 would qualify, regular monitoring of labs and health may be sufficient, without medications. Maintaining a healthy lifestyle is a good thing at all stages of disease.

The basic mechanism of immune deficiency in HIV is simply the depletion of T cells, leading to an inability of the immune system to respond to infections. There are many subtle things that happen along the way, and some details are not fully worked out, but I wouldn't think it correct to say that the mechanism through which HIV becomes AIDS is not understood. You get below 200, you have AIDS. On antiretroviral therapy, most patients will get T-cell counts above 200 CD4 cells. It really doesn't matter what you call it; they are restored to health. Again, AIDS is a term that is more of epidemiological use than medical use. The medical situation is simply advanced HIV infection.

Please check out the included web sites for more information.

--John Barrow

Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa [South African Government Website]:
http://www.info.gov.za/issues/hiv/careplanqa.htm

International HIV Care, Treatment, and Prevention Guidelines [HIV InSite]:
http://hivinsite.ucsf.edu/global?page=cr-00-04

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