Question:

My ex who is now one of my bestfriends was HIV+ when we started dating as was I myself. He was recently taking Atripla which is the same regimen that I am on. However, his doctor took him off the regimen and placed him on Sustiva and Truvada (which is the same as Atripla) as well as AZT. He said that prior to this he was doing fine on the old regimen neither progressing nor regressing. Yet when they added the AZT to the regimen, and broke the Atripla down to it's respective counterparts, his CD4 cells rapidly shot up. Mine are steadily climbing from less than 20 CD4 cells to my visit today of 482.

My question is this actually four fold:
A.) what reasons would the doctor change his regimen if he was stationary at an okay number?
B.) would it be wise to ask my doctor to add the AZT to my regimen?
C.) would this raise my CD4 cells as well?
D.) would this later cause complications with regimen failure or cause unnecessary symptoms (side effects)?

Answer provided by:

Daniel Lee, M. D.
Assistant Clinical Professor of Medicine
UCSD Medical Center
Owen Clinic

My initial thoughts are that I have never heard of anyone who might break up the components of Atripla and/or add AZT for the sole purpose of raising CD4 counts. In fact, AZT may partly lower CD4 counts artificially through its effect on lowering the white blood cell (WBC) count, which we know it can do. I'll answer each of your questions below.

A) I'm not sure why his physician would change his regimen if he was stable at an "okay" number. You probably need to ask your friend or his doctor as to why this was done. I would consider switching if there was some side effect, but I have not heard of adding AZT or changing to individual components of Atripla to improve CD4 counts.
B) I probably would not recommend adding AZT to your regimen as there is no data/research to suggest why this would increase your CD4 counts. However, this is something you should talk with your own doctor about if you are still interested.
C) I would not expect that adding AZT would increase your CD4 counts more. If you are undetectable, then you are already doing the best you can in regards to controlling the virus. It is up to your own immune system to build more CD4 counts. The problem is that we do not know how to build up CD4 counts faster.
D) Adding AZT may actually protect you from regimen failure as now you would have 4 drugs to treat HIV, making it harder to develop resistance, but at the expense of potential side effects (headache, nausea, anemia, neutropenia, lipoatrophy). With that said, it is possible that you may tolerate AZT fine as well. Just keep in mind that AZT is taken 2 times/day rather than once per day like Atripla, which may complicate things.

In regards to what has been studied to improve CD4 counts, I'll briefly relay a few bits of information:

1) IL-2 - Interleukin 2 has been studied and has been shown to increase CD4 counts, but is an injection and its effects stop after stopping it. In addition, IL-2 has a lot of side effects and can make someone feel like they have a flu. It is also not commercially available - only in research settings.
2) Kaletra - Interestingly, Kaletra has been shown in many studies to lead to a better CD4 cell count response, but exactly how and why this is the case is not at all clear. However, I have switched a few patients to Kaletra in an attempt to raise CD4 counts (per the patient's request) and have not noticed a significant difference.
3) Maraviroc - There have been some recent data to suggest that maraviroc may increase CD4 counts even in those who are resistant to it. There are now studies to look to see if adding it to a current regimen will lead to an improved CD4 count.

In my opinion, I do not necessarily recommend tweaking/adding a new medication to raise CD4 counts. Like I said, as long as your viral load is well controlled and undetectable, you are doing as best you can from a medical standpoint. Being undetectable will give your immune system the best chance to build itself up without HIV being in the way to destroy CD4 cells. However, we (researchers) still do not know how to stimulate one's immune system to rev up the production of CD4 cells. My recommendation, thus, is to live healthy - stop smoking, drug use, excess alcohol, and increase exercise and eat healthy and balanced meals.

Thanks for your question and good luck in your decision.

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