This month, James Oleske, MD, a professor of pediatrics at the New Jersey Medical School in Newark and a pioneering pediatric HIV researcher, discusses the viral load and CD4 count of Margaretha DeJesus, 6-year-old daughter of AIDS activist Marlene Diaz.
Children are not just little adults. That’s very important to remember when assessing Margaretha or any other HIV positive child. For example, CD4 counts are age-specific:
- For a child under age 1, a count of more than 1,500 CD4 cells (and greater than 25 percent—referring to the proportion of T cells represented by CD4s) is considered normal; 750 to 1,500 (15 to 25 percent) is considered moderate immune suppression; less than 750 (under 15 percent) is considered serious immune suppression.
- From ages 1 to 5, normal is more than 1,000 (and greater than 25 percent); moderate suppression is from 500 to 1,000 (15 to 25 percent); and serious suppression is less than 500 (under 15 percent).
- At the age of 6, a child’s CD4 count becomes comparable to an adult’s.
Luckily, until she was 6, Margaretha’s CD4s stayed between 1,200 and 1,500. Now that she’s approaching 7, her most recent count is 851 (shown as CD4 851), a sign of continuing immune strength.
The viral load is not so age-dependent. However, children who are born infected tend to have high viral loads, and it’s often very difficult to drive their viral loads below detectable levels. In the first year of life, we often have to be satisfied with just lowering the level. If it drops from a reading in the millions—typical in infants—to around 10,000, we’d probably accept that.
In fact, with kids of any age, we’re more tolerant of not achieving undetectable levels. With only eight anti-HIV drugs approved for them (seven of those in liquid form), children have fewer options than adults, so we’re less likely to switch therapies unless the jump in viral load is very significant. For example, an increase from undetectable to over 5,000—and certainly to 10,000 or more—combined with a significant CD4 drop might make me change a regimen.
Margaretha’s gradual viral load drops in response to therapy are typical. Her first count—at age 3 and a half—was 130,000. At 4, she was put on a combination of ddI (Videx), d4T (Zerit) and nelfinavir (Viracept). After six months, the viral load dropped to 10,000, but it took another two years for it to become undetectable. Her most recent count is 900 copies per milliliter (shown as HIV RNA PCR, 0.90 THOUS CPS/ML), but not a cause to switch therapy.
It is important that Marlene has always sought optimal care for Margaretha and monitored her carefully. Kids have many problems with adherence, so it’s crucial that an adult be available to make sure the drugs are taken regularly. When children are feeling relatively well, it can be very difficult to persuade them to take meds that may not only taste awful but make them feel sick.
But even meticulous parents may not know that the way some drugs are prescribed is problematic. For example, taking ddI on an empty stomach, as the manufacturer recommends, can cause stomach upset and nausea. This happened to Margaretha, who then wouldn’t eat her meals and lost weight. But research has found that ddI works well when taken after meals. After switching to that method, Margaretha again ate well and regained weight. This kind of small change can make a big difference. Another caution is remembering to increase drug dosage as the child gains weight. Sometimes a rise in viral load may be due to an insufficient drug dose.
By reaching out for information like this, Marlene has gotten Margaretha to take her meds properly, as well as to consume a good diet and a lengthy list of nutrient supplements (see “Pair of Aces,” POZ, December 1998). This combined approach has helped this child avoid the malnutrition, weight loss and growth failure for which HIV positive kids are at risk. And whenever Margaretha has developed problems—whether itchy skin, severe diarrhea or wasting—Marlene has aggressively used combinations of herbs, nutrients, homeopathic remedies and meds to resolve them. Today, Margaretha is healthy and in the normal range for both height and weight—all signs that her and her mom’s total approach is working and should be maintained.