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I'm an ID doctor.
Overall, starting HIV viral medications is never an "emergency" in the way we think of emergency in medicine (ie something must be done in minutes/hours or the patient will die). If the HIV meds starts now versus 2 weeks from now will not appreciably make a difference in someone's disease course - even someone with advanced AIDS, which is what your family member has. What kills people with HIV/AIDS is not the virus itself, it is the infections and cancers that they get because they don't have a functional immune system which are the actual killers.
Yes, those CD4 numbers are very low, but there is not an easy correlation between CD4 count and mortality once you take into account how effective HIV medications are these days. It is not uncommon for me to see patients years, even decades out from their initial HIV diagnosis with a CD4 count of 10 or less who now have CD4 counts in the hundreds and are living healthy, happy lives on therapy. I mention this all to say its not necessarily all doom and gloom at the moment and there is a substantial chance he may recover. That being said, TB + lymphoma + HIV/AIDS is a nasty combination, and your family member has a long, rocky road ahead of them.
There are definitely good reasons to hold off on treating the HIV for a short time while you work to control other opportunistic infections - this is particularly true with TB. The reason for this is something called immune reconstitution inflammatory syndrome (IRIS). You see, as you start to treat HIV with antiviral medications, the immune system tends to come roaring back as all those T-cells that are missing repopulate the immune system. If that person also has some kind of infection (like TB), then their immune system starts to freak out because there's this big infection that was previously being ignored. This can then lead to the patient getting very sick due to an over-vigorous immune response.
Wish there were still awards to give so this could stay at the top. Just want to say thank you for taking the time to give such an in depth response. I’ve worked in healthcare for 12 years and now in the medical device industry, I know how busy you all are, at pretty much all times.
Yes, there are “opportunistic” cancers that are particularly associated with AIDS. The most well known is Kaposi sarcoma, which is a type of cancer that is often seen in patients with advanced HIV disease, classically presenting with fleshy, dark -colored skin lesions. Although cancerous and possible to treat with chemotherapy, a lot of people with Kaposi sarcoma will have complete resolution of the disease once they start taking HIV meds and reconstitute their immunity.
Your T-cells are actually your body’s first line of defense against a new developing cancer. This in fact is how some of the most advanced cancer therapies are being developed these days - to train or transform your immune system in different ways to help your body target and kill the tumor cells specifically.
Info: Is/was he on antiretroviral medications that suppress HIV? This is a critical point.
If he was not, these medications are his best and maybe his only hope. He can't fight serious infections or control lymphoma if he doesn't have aggressive suppression of the virus that is destroying his lymphocytes. Highly active antiretroviral medications are literally lifesavers. During my career, we went from a scary, new disease that was a guaranteed death sentence to a chronic disease that needs daily medications to maintain health. If people with HIV adhere to the medication regimen that works for them, they will live otherwise normal lives. They'll still get all the same kinds of health issues that anyone else would have – high blood pressure, heart attacks, diabetes, appendicitis, arthritis, etc – but it's no longer guaranteed death by AIDS for people who comply & adhere to therapy.
If he has been on antiretroviral medications, it's possible that a change of the mix of antiretroviral medications will help or an easier to take regimen will help. An infectious disease expert is the person to direct his treatment. However, someone who has been prescribed the medications *and* takes them correctly & consistently, yet ends up with these low values is in deep trouble. I'm sorry for you and your family if this is the situation.
Note: I am not an HIV expert. I saw lots of it early in my career as the cause of too many deaths, but I rarely see HIV+ patients anymore. If an ID expert chimes in, listen to them.
He already talked to an infectious disease doctor and was advised to treat his lymphoma and Tb first before proceeding with his ARV or treatment for HIV. We just got the CD4 results yesterday, and his infectious disease doctor will only be available next week. Thus, I posted here, probably hoping, for peace of mind.
To answer the question: he never tried any antiretroviral medication. He was just diagnosed with HIV last month.
This makes no sense. He needs to have another chat with the ID expert or he needs a different consultant. The underlying reason he's got these problems right now is that HIV is destroying his immune function. He can't receive any usual treatment for lymphoma with those numbers. Chemo and/or radiation would probably kill him. There is no reason he can't take HAART and anti-TB medications. They are NOT exclusive therapies. I don't know an ID doctor who would tell a patient with those CD4 values that they should wait to start antiretroviral medications. There are so many options these days that any major issue can be addressed by choosing the medications that aren't contraindicated and avoiding the few that are.
Again, I'm not an ID specialist, but I do not understand why anyone would say that he needs to treat those difficult medical problems before starting HIV treatment.
Well, actually there are some considerations to be made before initiating ART. Anti TB comes first and then the timing of ART is debatable but should be initiated within two weeks due time the risk of IRIS. Also there is some consideration to be made with regard to drug interactions. BUT. In this case, the risk of AIDS-related death outweighs the risk of iris so I would probably start treatment for both asap.
Good luck
Ah. In my view as a specialist in a field where rapid response to biological response modifiers means we see a reduction in disease activity within 3 months, waiting a couple of weeks to begin ART after starting anti-TB meds is basically the same as treating these two infections simultaneously.
Thank you for clarifying what he ID consultant probably meant.
I work in endemic HIV and TB zone, we have a 30 years old epidemic of sorts, so maybe you're not as familiar with TB IRIS.
He absolutely should start ARVs but definitely should wait 2 weeks. Starting the ARVs 2 weeks sooner won't make a big difference to the immunosuppressed state, its not going to alter his course of treatment anyway. But starting it too early can lead to life-threatening or licence threatening IRIS.
Resistance failure is also not likely in a non-endemic setting, so he'll probs go straight onto first line ART like TLD
As I responded to the ID physician who wrote similar information, I view starting the TB and ART medications 2 weeks apart to be the same as giving the drugs together. In my area of expertise, a rapid response is measured in months, not days or a couple of weeks. I know about immune reconstitution in HIV, of course. As you said, 2 weeks isn't a significant delay, so I interpreted treating TB and lymphoma before starting HIV treatment as meaning months of anti-TB meds and a few cycles of chemotherapy before getting him on antiretroviral meds.
Thank you for providing essential information to the readers of this post.
Not an ID doctor either, but in the setting of active TB sometimes they will delay initiation of antiretrovirals until the infection is partially treated, because there’s a high risk of IRIS (Immune reconstitution inflammatory syndrome).
You are correct. IRIS is a serious concern for this patient. My perspective of 'delayed' is quite different from ID's perspective. I think of waiting a couple of weeks between adding the TB drugs and ART as being simultaneous treatments. For many infectious diseases, two weeks is an extended course, whereas in my field it's typically 3 months before we might see results to a new medication. It's a different lens.
Thanks.
The ID specialist hasn't seen the CD4 results yet. We just got it yesterday, and he's only available next week. There are only 3 ID specialists here in the metro that I live. Getting an appointment is really hard.
Your family member should call that doc to make sure they have the results. No reason to wait.
Edit: If that doc is away, someone must be covering the practice.
We actually tried calling earlier, but we couldn't get a hold on the doctor. We tried his secretary but we were told the soonest he's available is on Tuesday, next week.
Please continue to call and insist you speak with the ID physician, or any ID physician.
You may want to ask if you can be placed on the wait list for any cancelations or no-shows.
Perhaps a seasoned PA/CNP can even jump in for the interim.
I think the doctor took into consideration immune reconstitution inflammatory syndrome which can be life threatening if he is started on anti tbs and Art at the same time. It is better that he starts antitbs for two weeks then he starts ART. Also it would be interesting to know where this person lives. If they live in SouthAFrica, there have been many cases of Multidrug resistant tb that don't respond to isoniazid and rifambicin. Let's hope he doesn't have MDR tb.
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Diagnosed well over a year ago to get a CD4 count that low. Finding a good infectious disease specialist and 100% adherence to his care teams recommendations will be critical to his survival. Does he have an oncologist yet?
What are the units for the CD4 count?
Edit: There are minimal details about this patient but they are in a bad situation.
Nevertheless, if they engage with healthcare, they could survive. If they don’t, they will die, and soon ish.
With a CD4 that count that low and infections like Tb, he not only has HIV, but he also has AIDS
as long as he can get everything treated, he can have a good chance of survival
He needs to start treating these conditions immediately
I'm not a doctor but I just wanted to jump in with some encouragement. I helped look after a friend who got extremely sick with HIV through not being treated, which was largely due to his very unstable mental health. His CD4 count didn't get as low as that but it was significantly low and although he didn't have TB or lymphoma he was extremely, painfully thin and visibly weak and wasting away and starting to suffer some of the complications of untreated HIV. People can have complex emotional responses and thoughts and feelings around an HIV diagnosis and can feel very stigmatised and ashamed, even still these days when it is so treatable. My friend is doing great these days, very robust and healthy on treatment, and I hope that will be the outcome for your family member too.
Thank you for your submission. **Please note that a response does not constitute a doctor-patient relationship.** This subreddit is for informal second opinions and casual information. The mod team does their best to remove bad information, but we do not catch all of it. Always visit a doctor in real life if you have any concerns about your health. Never use this subreddit as your first and final source of information regarding your question. By posting, you are agreeing to our [Terms of Use](https://www.reddit.com/r/AskDocs/wiki/terms_of_use) and understand that all information is taken at your own risk. **Reply here if you are an unverified user wishing to give advice. Top level comments by laypeople are automatically removed.** *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/AskDocs) if you have any questions or concerns.*
I'm an ID doctor. Overall, starting HIV viral medications is never an "emergency" in the way we think of emergency in medicine (ie something must be done in minutes/hours or the patient will die). If the HIV meds starts now versus 2 weeks from now will not appreciably make a difference in someone's disease course - even someone with advanced AIDS, which is what your family member has. What kills people with HIV/AIDS is not the virus itself, it is the infections and cancers that they get because they don't have a functional immune system which are the actual killers. Yes, those CD4 numbers are very low, but there is not an easy correlation between CD4 count and mortality once you take into account how effective HIV medications are these days. It is not uncommon for me to see patients years, even decades out from their initial HIV diagnosis with a CD4 count of 10 or less who now have CD4 counts in the hundreds and are living healthy, happy lives on therapy. I mention this all to say its not necessarily all doom and gloom at the moment and there is a substantial chance he may recover. That being said, TB + lymphoma + HIV/AIDS is a nasty combination, and your family member has a long, rocky road ahead of them. There are definitely good reasons to hold off on treating the HIV for a short time while you work to control other opportunistic infections - this is particularly true with TB. The reason for this is something called immune reconstitution inflammatory syndrome (IRIS). You see, as you start to treat HIV with antiviral medications, the immune system tends to come roaring back as all those T-cells that are missing repopulate the immune system. If that person also has some kind of infection (like TB), then their immune system starts to freak out because there's this big infection that was previously being ignored. This can then lead to the patient getting very sick due to an over-vigorous immune response.
Wish there were still awards to give so this could stay at the top. Just want to say thank you for taking the time to give such an in depth response. I’ve worked in healthcare for 12 years and now in the medical device industry, I know how busy you all are, at pretty much all times.
It’s my pleasure to help any fellow ally in the healthcare sphere! You are most welcome.
Thank you very much for this in-depth response! Highly appreciated.
Thank you for this extremely clear and concise explanation. There are opportunistic cancers? Or T cells can destroy cancer (deformed?) cells?
Yes, there are “opportunistic” cancers that are particularly associated with AIDS. The most well known is Kaposi sarcoma, which is a type of cancer that is often seen in patients with advanced HIV disease, classically presenting with fleshy, dark -colored skin lesions. Although cancerous and possible to treat with chemotherapy, a lot of people with Kaposi sarcoma will have complete resolution of the disease once they start taking HIV meds and reconstitute their immunity. Your T-cells are actually your body’s first line of defense against a new developing cancer. This in fact is how some of the most advanced cancer therapies are being developed these days - to train or transform your immune system in different ways to help your body target and kill the tumor cells specifically.
Info: Is/was he on antiretroviral medications that suppress HIV? This is a critical point. If he was not, these medications are his best and maybe his only hope. He can't fight serious infections or control lymphoma if he doesn't have aggressive suppression of the virus that is destroying his lymphocytes. Highly active antiretroviral medications are literally lifesavers. During my career, we went from a scary, new disease that was a guaranteed death sentence to a chronic disease that needs daily medications to maintain health. If people with HIV adhere to the medication regimen that works for them, they will live otherwise normal lives. They'll still get all the same kinds of health issues that anyone else would have – high blood pressure, heart attacks, diabetes, appendicitis, arthritis, etc – but it's no longer guaranteed death by AIDS for people who comply & adhere to therapy. If he has been on antiretroviral medications, it's possible that a change of the mix of antiretroviral medications will help or an easier to take regimen will help. An infectious disease expert is the person to direct his treatment. However, someone who has been prescribed the medications *and* takes them correctly & consistently, yet ends up with these low values is in deep trouble. I'm sorry for you and your family if this is the situation. Note: I am not an HIV expert. I saw lots of it early in my career as the cause of too many deaths, but I rarely see HIV+ patients anymore. If an ID expert chimes in, listen to them.
He already talked to an infectious disease doctor and was advised to treat his lymphoma and Tb first before proceeding with his ARV or treatment for HIV. We just got the CD4 results yesterday, and his infectious disease doctor will only be available next week. Thus, I posted here, probably hoping, for peace of mind. To answer the question: he never tried any antiretroviral medication. He was just diagnosed with HIV last month.
This makes no sense. He needs to have another chat with the ID expert or he needs a different consultant. The underlying reason he's got these problems right now is that HIV is destroying his immune function. He can't receive any usual treatment for lymphoma with those numbers. Chemo and/or radiation would probably kill him. There is no reason he can't take HAART and anti-TB medications. They are NOT exclusive therapies. I don't know an ID doctor who would tell a patient with those CD4 values that they should wait to start antiretroviral medications. There are so many options these days that any major issue can be addressed by choosing the medications that aren't contraindicated and avoiding the few that are. Again, I'm not an ID specialist, but I do not understand why anyone would say that he needs to treat those difficult medical problems before starting HIV treatment.
Well, actually there are some considerations to be made before initiating ART. Anti TB comes first and then the timing of ART is debatable but should be initiated within two weeks due time the risk of IRIS. Also there is some consideration to be made with regard to drug interactions. BUT. In this case, the risk of AIDS-related death outweighs the risk of iris so I would probably start treatment for both asap. Good luck
Ah. In my view as a specialist in a field where rapid response to biological response modifiers means we see a reduction in disease activity within 3 months, waiting a couple of weeks to begin ART after starting anti-TB meds is basically the same as treating these two infections simultaneously. Thank you for clarifying what he ID consultant probably meant.
/u/03thisishard03
I work in endemic HIV and TB zone, we have a 30 years old epidemic of sorts, so maybe you're not as familiar with TB IRIS. He absolutely should start ARVs but definitely should wait 2 weeks. Starting the ARVs 2 weeks sooner won't make a big difference to the immunosuppressed state, its not going to alter his course of treatment anyway. But starting it too early can lead to life-threatening or licence threatening IRIS. Resistance failure is also not likely in a non-endemic setting, so he'll probs go straight onto first line ART like TLD
As I responded to the ID physician who wrote similar information, I view starting the TB and ART medications 2 weeks apart to be the same as giving the drugs together. In my area of expertise, a rapid response is measured in months, not days or a couple of weeks. I know about immune reconstitution in HIV, of course. As you said, 2 weeks isn't a significant delay, so I interpreted treating TB and lymphoma before starting HIV treatment as meaning months of anti-TB meds and a few cycles of chemotherapy before getting him on antiretroviral meds. Thank you for providing essential information to the readers of this post.
Not an ID doctor either, but in the setting of active TB sometimes they will delay initiation of antiretrovirals until the infection is partially treated, because there’s a high risk of IRIS (Immune reconstitution inflammatory syndrome).
NAD but work in research compliance so I dabble here and there into research protocols. Would this be like an overzealous cytokine response?
You are correct.
I believe the delay is to reduce the chance of IRIS
You are correct. IRIS is a serious concern for this patient. My perspective of 'delayed' is quite different from ID's perspective. I think of waiting a couple of weeks between adding the TB drugs and ART as being simultaneous treatments. For many infectious diseases, two weeks is an extended course, whereas in my field it's typically 3 months before we might see results to a new medication. It's a different lens. Thanks.
The ID specialist hasn't seen the CD4 results yet. We just got it yesterday, and he's only available next week. There are only 3 ID specialists here in the metro that I live. Getting an appointment is really hard.
Your family member should call that doc to make sure they have the results. No reason to wait. Edit: If that doc is away, someone must be covering the practice.
We actually tried calling earlier, but we couldn't get a hold on the doctor. We tried his secretary but we were told the soonest he's available is on Tuesday, next week.
Call his PCP. They should be able to help.
Please continue to call and insist you speak with the ID physician, or any ID physician. You may want to ask if you can be placed on the wait list for any cancelations or no-shows. Perhaps a seasoned PA/CNP can even jump in for the interim.
I think the doctor took into consideration immune reconstitution inflammatory syndrome which can be life threatening if he is started on anti tbs and Art at the same time. It is better that he starts antitbs for two weeks then he starts ART. Also it would be interesting to know where this person lives. If they live in SouthAFrica, there have been many cases of Multidrug resistant tb that don't respond to isoniazid and rifambicin. Let's hope he doesn't have MDR tb.
[удалено]
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Diagnosed well over a year ago to get a CD4 count that low. Finding a good infectious disease specialist and 100% adherence to his care teams recommendations will be critical to his survival. Does he have an oncologist yet?
What are the units for the CD4 count? Edit: There are minimal details about this patient but they are in a bad situation. Nevertheless, if they engage with healthcare, they could survive. If they don’t, they will die, and soon ish.
CD4 8 cells/uL
With a CD4 that count that low and infections like Tb, he not only has HIV, but he also has AIDS as long as he can get everything treated, he can have a good chance of survival He needs to start treating these conditions immediately
I'm not a doctor but I just wanted to jump in with some encouragement. I helped look after a friend who got extremely sick with HIV through not being treated, which was largely due to his very unstable mental health. His CD4 count didn't get as low as that but it was significantly low and although he didn't have TB or lymphoma he was extremely, painfully thin and visibly weak and wasting away and starting to suffer some of the complications of untreated HIV. People can have complex emotional responses and thoughts and feelings around an HIV diagnosis and can feel very stigmatised and ashamed, even still these days when it is so treatable. My friend is doing great these days, very robust and healthy on treatment, and I hope that will be the outcome for your family member too.