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By Julene Tripp Weaver

The Numbers Game

A new blood test, the viral load, is now available giving everyone dealing with HIV or AIDS more numbers to cause anxiety. This new marker indicates how much viral activity is in the blood and doctors are using it to decide combination treatment therapies. The use of this new blood test has changed the way doctors treat HIV, the aim being to reduce the viral load so it is undetectable in the blood and to keep it undetectable. For right now undetectable means a viral load result would be somewhere under four hundred. A new viral load test will be available soon that will show undetectable at under twenty.

In my work as a case manager I see clients with a wide range of viral load counts and CD4 counts. Someone may have a low CD4 count (under fifty) and a very high viral load (near one million) yet they feel fine and have no opportunistic infections; meanwhile another person with a viral load of thirty thousand and a CD4 count of four hundred can be very sick. Despite the unaccountability of what some people experience, mathematical equations are published that give life expectancy based on viral load tests. A common experience I hear is someone feels great, their stress is down, things seem to be doing fine, and then that person goes in for a blood test. He or she expects it to come back better, or at least stable, and then the result comes back and it is not what is expected. In the context of the mathematical model it can be a surprise if the numbers are not good while one is feeling well. Obviously, these tests do not necessarily reflect what a person is feeling and this may lead to confusion, anger or depression. Is this a familiar experience? It can lead anyone to question if they can trust how they feel. The numbers game can have a strong influence on ones subjective experience; it can erode one's belief in health and promote pessimism about one's healing capabilities.

AIDS research is constant; some of this research is hopeful with new possible cures around the corner, and other research delivers news that is not good. Keeping a positive attitude is a vital component to a high quality of life whether one judges the current research information good or bad. The numbers are important, yes, but do they really govern your health, and should you allow them to govern how you feel about yourself? Research in psychoneuroimmunology (a big word for the study of the impact of psychological factors on immunological diseases) shows that certain psychological states lead to faster progression to AIDS and death, while other psychological states improve immunity and survival.

It is too early to know what these new additional anxiety producing numbers really mean. There are some reasons not to jump to the conclusion of using mathematical formulas to predict life expectancy based on viral load results. Dr. David Ho, the first researcher to experiment with combination therapies, speculates that if the viral load can be kept undetectable for up to three years it is possible to eradicate HIV. This is a theory that has not been proven. If the virus does not show in the blood there are other places it may be hiding such as the lymph nodes or the brain that are harder to test. Many things influence the viral load test. For example, a flu immunization shot will cause a high viral load result. There are many variables that may affect individual responses to the virus despite what the numbers may be.

A thought provoking article reports on a study of immune reactions when someone is first infected with HIV. In the 1/18/97 issue of Science News the article, "Course of AIDS Foretold by T Cells," a study by scientists, including Dr. Anthony Fauci of the National Institute of Allergy and Infectious Diseases, documents a strong immune system attack on HIV at the initial infection. Dr. Fauci claims the immune system is far from helpless, and that HIV's ability to elude the immune system's onslaught and then rebound makes HIV unique. "No other virus, except Herpes and possibly Hepatitis B, evades destruction without overwhelming and killing the infected individual. Herpesviruses flee into latency, chronic infections with Hepatitis B is unusual, but HIV not only survives, it thrives."

This article outlines the three different approaches they found the immune system uses to first counter the HIV virus. The study implies that how the immune system initially activates in its defense may set the course of the illness. They examined the interplay of HIV and immunity. There are up to 24 identified families of T cells, to date (This is the first place where I have read about the twenty-four families of T cells). It is a challenge to know what ones CD4 count was before HIV entered the picture, but scientists in this study and generally use the average of twelve hundred. Of the twenty-one people in the study they found three different patterns of response:
Pattern number 1 : HIV provoked a major expansion of a single family of T cells. This flood of a single T cell family did the worst in the long run. In one year the T cell counts dropped to an average of 101 per microliter of blood, too few to ward off other infections.
Pattern number 2: In the second response HIV provoked two families of T cells to multiply. These people fared better their T cells dropping slower, after a year the count had dropped to an average of 456 per microliter of blood.
Pattern number 3: The third response was "scattershot production of small quantities of T cells from a diverse array of families." This group had the slowest decline of T cells and the average T cell count after a year was 651 per microliter of blood.

It makes sense that people have different initial responses to the virus, and perhaps there are more than these three responses. Again, this causes me to question how one can calculate life-expectancy based on a mathematical model. Recently I learned that many AIDS doctors are treating patients based on their lowest ever CD4 count, not their most current one. Current research is raising the issue that newly made CD4 cells may not be as good as the original batch, and there is concern that whole families of T cells might be lost. With the mathematical model so predominant now there is no way to measure this information.

Another article that examines this further is, "With AIDS Advance, More Disappointment." In the New York Times on 1/19/97, it states, "Research by Dr. H. Clifford Lane at Dr. Fauci's institute suggests that when an AIDS patient's CD4 count drops, certain types, or clones, of CD4 cells are lost. These are the ones that may allow the immune system of such a patient to respond to the specific infectious agents that cause opportunistic infections in AIDS. But even when the overall CD4 count rises after an individual starts combination therapy, certain clones may be lost permanently." These clones are possibly the families referred to in the previous article, hence the trend of doctors to treat any current symptom as if you were at the lowest CD4 count you've ever had, hence the urging to treat early and not let your T cells drop so low that you might lose families and make inferior cells.

This news is not the best, but it is significant to know the most current data. With the input of a doctor, knowing this information will help guide the decision making process about when to start medication or to change to a new regimen. Being aware of the research, questioning it, talking with a doctor, friends, and a treatment hot line will help ensure the best care and best decisions are made. It is also important to stay in touch with how you actually feel and not let the numbers, the mathematical equations, or the life expectancy guesstimates become your determining factors. Remember that according to the psychoneuroimmunology research those who believe in the fatalistic point of view, and hold onto fear and panic, are more likely to decline faster. On the other hand, those who are self-assertive, have a sense of purpose, and set goals for the future will have a strengthened immune system. There are many unanswered questions, and people are too variable in their responses to illness to take the mathematical approach as a given. Many people live long beyond what the numbers would predict, after all, life is more than the sum of the numbers.