Volume 2, Number 4HIV Counselor

PERSPECTIVESWriffen and Produced by the UCSF AIDS Health Projectfor the California Department of Health Services, Office ofAIDS

CELLS

RESEARCH UPDATE

T-HELPERT-l'elper cells, also known as CD4

cells, are white blood cells of the body'simmune system that help tlte body fightdisease. For a persOIl with HfV, a declinein the /llimber ofT-helper cells is one ofa!lumber of markers that HTV disease liasprogressed, and it indicates a risk of ftt­tllre progression. T-helper cell COU1Its aremeasured by laboratory blood tests. Othermarkers ofHIV disease progression mea­sured by laboratory tests and used illclinical practice include beta-2 micro­globutin, neopterin, p24 antigell a/ldp24 mltibody. These markers are ex­plained ill greater detail beghming allpage 4.

normally range between 700 and1,300.1 In a person with HlV, adecline reveals that thesecells have

who is not infected with HTV, T- been eliminated - most likelyhelper cells coordinate the body's because HIV has infected add i-response to fight and eventually tional T-helper cells - and there-eliminate the organism. fore, the body's immune system

When a person is infected with has weakened and is less able toHIV, the virus selectively invades defend itself against infections.T-helper cells, and becomes a part T-helper cell counts are con­of these cells. Atthis stage, T-help- sidered the best test to evaluateer cells may slow HIV from ad- the health of the immune systemvancing, but they are unable to for a person with HIV. Many re-eliminate HTV from the cells that searchers consider T-helper cellare already invaded. Treatments counts the "most important fea­can aid in slowing the progression ture in predicting short-term riskof the virus and increasing the of developing clinical signs of dis­number ofT-helper cells. Howev- ease."2 A conference on the use ofer, during an extended period, the antiviral drug zidovudinewhich may stretch for several (AZT) in early H1V disease con*years, HIV gradually becomes cluded that the T-helper cell countmore aggressive and spreads to a is the only laboratory test neces-larger number of cells. These cells sary in deciding when to begin

T-Helper Cells treatment with AZT.are unable to defend against HIV,

T-helper cells are one of sever- II d ed d Clinicians useT-helper cell lev-they are eventua y estray anal kinds of white blood cells in the els to determine the degree tothe immune system becomes in*body and they are the immune k 0 which infection has progressed,creasinglywea ened. pportunis-system's primary line of defense in! k d f and to determine appropriate in-tic' ections ta e a vantage 0in fighting infections, including terventions. Researchers and di-the weakened immune system toHIV. While a decline in T-helper nicians have arrived at the follow-cause disease.cell counts is an indicator of a sup* h I II ing general guidelines as a resultT- e per ce counts measurepressed immune system, it is not of studying T-helper cell levels inthe number of T-helper cells in aproof that a person is ill oris going cubic millimeter of blood. In people who have developed ill-to develop serious illness. In add i- ness.

healthy people who are not infect-tion, fluctuations in T-helper cell -500 or more. A T-helper celled with HIV, T-helper cell countscounts are not specific to r--_"':":~--_':'-_':"':_--~------, count of at least 500 is con-mv iruection; rises and falls Inside This Issue sidered tobeabovetherangeoccur in people who are not Research Update 1 for which HIV treatmentsinfected with HIV. A Related Issue: Defining AIDS _ are recommended by physi*

A healthy body has an The Role of T-Helper Cells 3 cians as a standard practice.enormous number of T- Implications for Counseling 5 At this level, immune-relat-helper cells. When an or- Case Study 7 ed diseases are extremelyganism, such as a common Test Yourself 8 rare. Most people with HIVflu virus, invades the im- Discussion Questions 8 maintain T-helper cellmune system of someone How to Use PERSPECTIVES B counts of at least 500 for

PAGE 2 PERSPECTIVES

"Start of study was not related to time of seroconversion.

Subjects with HIV Who Developed AIDS ThreeYears after Entering Study·

the study developed AIDS withinthree years, compared to 16% ofthose with countsgreaterthan400.'Illnesses occurwith increasing fre­quency for people with T-helpercell counts between 50-200, and itis at this pointthat a person shouldhave his or her health monitoredat least every two months, and con­sider prophylactic treatment forother opportunistic infections, in­cluding cytomegalovirus (CMV),toxoplasmosis and mycobacterillmavillm illtracellulare (MAl or MAC).

-Less than 50. In some cases,serious cases of life-threateningHIV-related illnesses do not de­velopuntila person'sT-helpercellcount has fallen below SO; onestudy of patients receiving thor­ough treatment found it extreme­ly rare for HIV-related death tooccur before this time.7 Some pe0­

ple with HIV may have T-helpercel1 counts below SO, yet not haveserious illnesses. This is often be­cause infections are being success­fully prevented by prophylaxis.

Variable Results

T-helper cell counts can varydramatically for reasons that ap­pear to have little to do with over­all health status.

For instance, differences in lab­oratory techniques can result incounts that differ by as much as20%. In addition, T-helper cellcounts vary naturally in any per­son over time - even from day today - for reasons that are inde­pendent of HlV infection, butwhich are poorly understood. I Forexample, normal variation wouldallow for a T-helper cell count ofSOOatone time and perhaps 400 or600 on a follow-up test. Test re­sultscan vary based on the tirneofday they are performed; the exist­ence of other medical conditions,such as colds; the presenceofmed­ications; and vigorous exercise.

To reduce variations, succes-

87%

mune suppression and risk of fur­ther decline. T-helper cell tests forpeople with counts between 200­499 should be measured everythree months.

Clinical signs of disease gen­erally are not detected until a per­son's T-helper cell count falls be­low 500. Clinical markers, whichcan be used to measure a person'simmune status, include oral can­didiasis, also known as thrush;hairy leukoplakia; herpes zoster;and lymphoma-like symptomssuch as drenching night sweats,sustained weight loss and persis­tent high-grade fever or diarrhea.

-50-199. As part of a recentlyexpanded definition of AIDS pro­posed by the federal Centers forDisease Control (CDC), a personwould be diagnosed with AIDSwhen his or her T-helpercell countfalls below 200. This proposedchange has been delayed indefi­nitely. A T-helper cell count be­tween 50-200 is considered a dan­ger sign for developing illness. In arecentstudyofgay men with HlV,87% of those with T-helper cellcounts of 200 or less at the start of

16%25%

50%

75%

100%

several years. People with HIVwho have T-helper cell countsgreater than 500 should receive T­helper cell tests twice a year.

-200-499. Antiviral treatmentis recommended when T-helpercell counts fall below 500. Studieshave found the drugs AZT anddidanosine (ciciO to be beneficialin delaying disease progression forpeople with T-helper cell countsbelow SOO.3 AZT has been shownto boost T-helper cell levels for anindefinite period that may extendseveral years.~For most people nottaking treatment, T-helper cellcounts steadily fall. Even withtreatment, T-helper cell countsusually decline over time.

Preventive, or prophylactic,treatment against the opportunis­tic infection Pnellmocystis cariniipneumonia (PCP) is suggested forpeople with T-helper cell countsbelow 250.5 Most serious HlV-re­lated diseases do not develop inpeople vvith T-helper cell countsbetween 200-499. However, T­helper cell counts betvveen 200­499 are interpreted with cautionbecause they show increased im-

T-Helper Cell Counts and AIDS Risk' I

T-helper cell counts of T-helper cell counts of400 or more at start of study 200 or less al start of study

T-HELPER CELLS PAGE 3

sive tests should be performed bythe same laboratories at similartimes of the day. Researchers rec­ommend that at least two tests beconducted before taking actionbased on a result.

Disease Progression

T-helper cell counts in peoplewith I-UV decline by an average of

80-100 per year. 1 Because this is anaverage, some lose more cells peryear, while others lose fewer. In aperson with HJV, several years usu­ally go by before the body loses somany T-helper cells that the im­mune system becomes unable todefend itseU against other infec­tions. After infection, most peopledo not develop clinical symptoms

of disease for five to eight years. Alarge study of gay men found that1% developed AIDS within twoyears of infection, 8% within fOUf

years, 20% within six years, 36%within eight years, and 53% with­in 11 years of infection.8

Currently, most people infect­ed with HJV are free ofsymptoms,and they likely have T-helper cell

A Related Issue:Defining AIDS - TheRole of T-Helper Cells

The Centers for Disease Control (CDC) hasproposed new criteria for its AIDS case defini·tionY The CDC's existing definition assigns anAIDS diagnosis only in the presence of at least oneof a number of opportunistic infections, such asPlleumocystis carillii pneumonia (PCP), KapoSi'Ssarcoma (KS), or toxoplasmosis. The proposedcriteria expand the definition to include either oneof these diseasesor aT-helper cell count below 200.The definition, first proposed in the summer of1991, was repeatedly postponed and in June 1992its implementation was postponed indefinitely.

Some believe the proposal to be cancelled.Regardless, the attempt to give merit to laboratorymarkers such as T-helper cells is significant. And,it signals the growing importance of looking atsuch markers, and not only the presence of certainopportunistic diseases, in viewing HIV infection.

The CDC sought to expand its definition inpart to more accurately count the number of peo­ple with advanced signs ofI-ITV disease. While theCDC has changed its definition of AIDS severaltimes since the original definition was establishedin1982, the proposed revision is the first to includea laboratory marker of progression such as a T·helper cell count. Earlier definitions were made ata time when little was known about laboratorymarkers, and they were based on diseases seen inhomosexual men. They did not incIudeconditionscommonly seen in injection drug users and wom­en, who have been increasingly affected by HIV.

Thedefinition change has drawn criticism fromsome who believe it does not include all people atadvanced stages of HIV infection. Specifically, thenew definition does not include pulmonary tuber-

eulosis, seen often in injection drug users, and vag­inal candidiasis, which is common among womenwith HN. Advocates say many people suffer theseand other non-AIDS defining illnesses despite T­helper cell counts greater than 200.

If additional diseases were considered., doctorsmay recognize conditions as being associated withHIV disease, advise HIV antibody testing, and helppatients develop lilV treatment plans earlier in thecourse of disease.

Some people also believe the new definitionplaces toogreatan emphasis on T-heJpercell counts,and that a combination of markers should be used.Despite the drawbacks, the focus on T-helper celltesting means that more asymptomatic people whowould otherwiseavoid treatment would be prompt­ed to seek treatment when they receive an AIDSdiagnosis. While this may ultimately be beneficial,especially as treatments improve, it is important tonote that the definition in and of itself does notcJlange people's health. People with T-helper cellcounts of less than 200 are no less healthy with anAIDS diagnosis than they are without one.

The Effect on BenefitsWhilesome had hoped a definition change would

broaden the number of people eligible to receivepublic benefits, the Social Security Administrationhas established separate criteria to determine whena person with HIV is eligible for benefits.l~ Thiseligibility is based, not on a person's T-helper cellcount, but on factors more closely tied to whether aperson is healthy enough to work. Physicians canmake such claims on behalf of patients. Under thedefinition for these benefits, a person who has fewerthan 200 T-helper cells but is healthy enough towork, may not qualify.

While it is likely thatmorepeople will qualify forbenefits tmder the new benefits criteria, it is unlikelythat financial support from the government willincrease. Therefore, it may be more difficult to re­ceive benefits.

PAGE 4 PERSPECTIVES

"Study does not indkate length of time subjects had been infected.

T-Helper Cells and Development of Illness"

Subjects Who Developed Major Infectious Disease During12 Months Preceding Study - Based on T-Helper Cell Levels·

gression increases. The risk of pro­gression is especially increased atlevels higher than 3.5. One studyfound declines in beta-2microglob­ulin levels in people who begantherapy with AZT.lI

Neopterin

eopterin isa substance that isreleased into the blood by cellscalled macrophages in the pres­ence of a foreign agent such asHN.ln people who are not infect­ed with HfV, the neopterin level isgenerally about 5.4 milligrams perliter. Like the beta-2mlcroglobulinlevel, neopterin levels reflect stim­ulation of the immune system. In­creases in neopterin levels are areliable indicator of the presenceof a foreign agent, but neopterincan increase for reasons unrelatedto HfV. Clinicians generallydo nottest for both neopterin and beta-2microglobulin because these testsusually produce the same results.Neopterin tests are generally lessavailable than beta-2 microglobu­lin tests.

P24 Antigen

P24 is the core protein of HlV.When p24 antigen is detected, it isa sign that HIV is actively replicat­ing in the body. P24 antigen isoften present in the period imme·diately after HIV infection andshortly before a person developsantibodies to HIV. It then disap­pears for several years and reap­pears when l-IIV begins progress­ing more rapidly. It is rarely de­tected in asymptomatic peoplewith HIV after they have serocon­verted, or started producing anti·bodies. Therefore, it is generallynot a useful test for someone in theearly stages of infection.

P24 Antibody

A p24 antibody test measuresthe amount of this specific HIVantibody produced in response to

1()()%80%60%

45.6%

Because no single lab test, in­cluding aT-helpercell count, canbe considered completely accu­rate in determining the health ofa person's immune status, it isuseful to consider several differ·ent test results together. As withT-helper cell testing, the resultsofother testsareaffected notonlyby HIV but also by the presenceof drugs and medications andother infections. Most often, cli­nicians use T-helper cell counts'\vith either beta-2 microglobulinor neopterin tests.

Beta-2 microglobulinBeta-2 microglobuJin is a

molecule released into the blood­stream when a cell dies. Beta-2mlcroglobulin tests, which mea­sure the molecule in milligramsper liter of blood, can detect cellloss in people with HIV. Levelsbelow 3 are considered normalin healthy individuals. 10 Whenthe beta-2microglobulin level ris­es above 3, the risk of HIV pro-

40%20%0%

<200

2lJO.499

T-helpercellcount 500

counts greater than 500. Clinicalevidence has found that some pe0­ple have maintained T-helper celllevels higher than 500 for longerthan 10 years after being infected.

T-Helper Cell Percentagesor Ratios

While T-helper cells are mostcommonly reported in absolutenumbers, they can be reported as apercentage ofall T-lymphocytes.lnhealthy, uninfected individuals, T­helpercellsgenerally make up rnorethan 30% of all T-lymphocytes'Treatment with AZT is often rec­ommended when the T-helper cellproportion falls below 25%. Theper­centage is used because it variesless fromday-to-day than theabso­lute number of T-helper cells.

Other Markers

In addition to T-helper cellcounts, other markers are used toevaluate the health of the immunesystem and show whether HlV isactively replicating within thebody.

T-HELPER CELLS PAGE 5

p24 antigen. A person with re­duced levels of p24 antibody ismore likely to develop signs ofHIV·related disease. An antibodydecline is often detectable beforep24 antigen increases.

T-Killer CellsT-killer, areD8, cellsare white

blood cells capable of attackingHIV-infected cells, and either kill­ing them or suppressing the viruswithin them. According to a pre­sentation at the Eighth Interna­tional Conference on AIDS in July1992,adrop in thenumberofthesecells is followed by an onset ofHJV symptoms.12 This finding ispreliminary. Tests forT-killer cellsare not yet in widespread use.

Other Lab Tests

in addition to markers of pro­gression, many other laboratorytests evaluate general health orspecific infections. They includetests for kidney and liver function,syphilis, tuberculosis infection andcomplete blood count (CaC). Acae is a general purpose labora­tory test used as part of the evalu­ation of almost any condition. Acae counts the number of redblood cells, white blood cells, andplatelets.

References1. Bartlett JG, Finkbeiner AK. TIle Gllide to Liu­iug wilh HIV Infection. Baltimore: The JohnsHopkins University Press. 1991.

2. HIV surrogate markers weighed. jourllal oftile American Medical A5s0cialiou. 1991; 265(11):1360--1362.

3. Fischl MA, Richman DD, Hansen N, et al.The safety and efficacy of ridovudine{AZT) inthe treatment of subjects with mildly symp­tomatic human immunodeficiency viros type 1(J-1IVj infection. Anuals ofIntmral Medicinl'. 1990;112: n7-n7.

4. Vella S, Giuliano M, Pezzotti P, et al. Sur­vival ofzidovudine-treated patients with AIDSoompared with thai ofcontemporary untreatedpatients. ]OllTllfll ofthl' AmericOIl Medical Associa­tion. 1992; 267(9): 1232·1236.

5. Centers for Disease Control. Recommenda­tions for prophylaxis against pneumocystiscarinii pneumonia (PCP). Morbidity andMortal­ity W«kly Report. 1992; 41: RR4.

6. Moss AR, B.1cchelti P, Osmond D, et al.Seropositivity for HIVand thedevelopmcntofAIDS or AIDS-related condition: three yearfollow-up of the San Francisco General Hospi­rnloohon.BririshMl'dical ]oumal.1988;296: 745­

750.

7. Yarrhoan R. Venzon D, PludaJM, et al. CD4oountand the risk for death in patients infectedwith HIV receiving antiretroviral therapy. An­nalsoflntemal Medicine. 1991; 115(3): 184-189.

8. Lemp GF, Payne SF, Rutherford GW, et OILProjections ofAIDS morbidity and mortality inSan Francisco. ]ounwl of the American MlOicalAssociatirm. 1990; 263(11): 1497-1501-

9. Cohen PT, Sande MA, Volberding PA, cds.TIle AlDS KlIowll'dge Bast. Waltham, Mass; TheMedical Publishing Group, MassachusettsMedical Society. 1990.

10. Baker RA, Moulton JM, Tighe J. Early Carl'for HIV Disease, Second Editioll. San Frands<:o:San Francisco AIDS Foundation. 1992.

11. Bass HZ, Hardy 0, Mitsuyasu RT, et al. Theeffeel of zidovudine treatment on serumneopterin and Bet~-microglobu1in levels inmildly symptomatic, HIV type 1 seropositiveindividuals. IOI/Mlal of AcqUired Immlme Defi­ciency Syndromes. 1992; 5(3}:215-221.

12. Levy J. "Immunologic responses and Iong­term survival." Plenary Session, Eighth Inter­national Conference on AIDS. Amsterdam,Holland. July 22,1992.

13. Centers for DiseaseControl Reviewofdraftfor revision of I-!IV infection classification sys­tem and expansion of AIDS surveillance casedefinition. Morbidity alld Mortality Weekly Re­port. 1991; 40: 787.

14. Federal Register. 1991. 56(243): 65708-65711.

15. Famo KM, Buehler JW, Chamberland ME,et al. Spectrum of disease in PCTSQl1S with HIVinfection in the United States. joumal of IlleAmL7icanMl'dical Associatilm. 1992;267(3): 1798­1804.

IMPLICATIONS FORCOUNSELING

Markers of progreSSion are rel­evant to the antibody test counsel­ing session because they are a cli­ent's "next step" after receiving a

positive antibody test result. Afteran antibody test determines a per­son is infected, T-helper cell countsand other laboratory markers ofprogresSion can provide specificinformation about the status of aperson's immune system.

Counselors call address theimportance ofmarkers ofprogres­sion briefly in pre-test counselingby stating that clients who receivepositive test results can proceed tomanage infection with the help ofmedical intervention, which in­cludes tests for T-helper cells.

Discuss markers of progres­sion in a post-test counseling ses­sion by first determining a client'sknowledge of the steps to take tomanage HlV infection and receivehealth care. Make no assumptionsabout a client's knowledge relatedto markers ofdisease progression;clients may know a great dealabout HIV infection, yet know lit­tle about tests beyond the HlVantibody test.

Adjscussion about markers ofprogreSSion need not be lengthy.Present them asa valuable tool forclients to gauge their health statusand maintain some control of theirhealth. Specifically, results of lab­oratory tests are useful in makinginformed decisions about wheth­er to enter clinical trials, and ac­cept prophylactiC and antiviraltreatment.

Present the follOWing informa­tion:

- Review the basics about theactivity and progreSSion of mv.Explain that T-helper cells are thebody's primary defense againstHIY, and that T-helper cell countsare the most-often used marker ofHIV progresSion.

-Tests are available to deter­mine a person's immune status,and these tests are a valuable partof medical care for someone withHIV. Emphasize that once people

PAGE 6 PERSPECTIVES

are aware of their antibody sta­tus, the next step is to deter­mine immune system status.

-While a client's personaJperceptions of how well he orshe feels at the moment are im­portant, laboratory tests can gobeyond this to measure the de·gree to which the virus hasweakened the immune system.

• Tell clients they can obtainT-helper cell counts from phy­sicians. If they are interested,send or escort antibody posi­tiveclients to on-site health cen­ters-where available- forT­helper cell testingafter post-testcounseling. If such sites are notavailable, offer referrals to areamedical providers for thesetests.

In many cases, it will not benecessary to discuss markers ofprogression in any further de­tail. Discussing this technicalissue may confuse some clients,especially after antibody testresultdisclosurewhen manycli­ents are overwhelmed and notnecessarily ready to hear aboutor take additional steps. How­ever, many clients will find ituseful to talk in more detail.This is especially true for clients

A COUNSELOR'SPERSPECTIVE

"Clients are going tohear a lot about T-helpercells as soon as they startreceiving medica/monitor­ing. III many cases, 1giveclients their first exposureto hearing about T-helpercells by helpillg them under­staud the term and describ­ing its relevance."

who raise questions or concernsabout markers of progression, orthose who wish to know moreabout their health status and abouttaking control of their health care.

Some clients may place exces­sive trust in laboratory markers.Even if they feel healthy and haveno clinical signs of clisease, theymay believe that only their T-help­er cell result is significant. State toclients that no laboratory markeror combination of markers can de­finitively determine a person'shealth and prospects for the fu­ture, and that caution should beused in interpreting any result. Putlaboratory tests in properperspec­tive by stating that how a personfeels is Significant regardlessoflab­oratory test results. Explain that T­helper cell counts can fluctuatebroadly for reasons unrelated tosignificant changes in health, andthat tests need to be performedmore than once.

Resistance

Seropositive clients may resistseeking medical care or aT-helpercell test afterantibody testing. Theymay feel that seeking further healthcare is an acknowledgement thatthey are ill, or they may fear beingtold they are sick.

Anticipate this resistance, andrecognize that clients may not beready to manage infection. Remindtheseclients that they have alreadytaken the first significant step inlearning about their health and thatfailing to manage HN infection isdangerous. Empathize with clientswho are unwilling to go further.

Theseclients may bewilling toseek education or psychosocialsupport. Recommend that theyenter support groups for peoplewith HIY. They can also visit earlyintervention sites for health edu­cation or one-on-one counselingabout their health without receiv-

A COUNSELOR'SPERSPECTIVE

"A lot of eliellts, alldevw counselors, are con­fused and intimidated bythe T-helper cell test. TheyIleedn 't be. I see the test asa basic tool that can providesome useful directioll."

ing primary medical care. Theseclients may also be willing to set atime for themselves when they willbegin to manage infection.

Often, clients have many ques­tions about their health and theybelieve these can be answered by aT-helper cell test result. Be pre­pared with answers or appropri­ate referrals for clients' questions.The following are common ques­tions asked by clients:

• "If my T-helper cell count islow, how can I get it higher?"

A primary purpose of T-help­er cell testing is to know when tobegin treatment. For someonewhose immune system is sup­pressed, treatment with antiviralssuch as AZT or ddI may help sus­tain and perhaps boost T-helpercell counts. Exercise, stress man~

agementand proper nutrition andrest may also help boost T-helpercell levels. Poor nutrition and con­sumption of alcohol and otherdrugs may suppress the immunesystem and lower a person's T­helper cell count.

• "Why do I need follow-uptests right away?"

Thesoonera person seekssuchtests, the sooner he or she may beable to regain some control overhis or her health and takethestepsnecessary to stay healthy. By seek­ing such tests, a person may learnhe or she is at a stage of disease at

T·HELPER CELLS PAGE 7

Case StudyDavid is a 33-year-old who has tested. antibody

positive. He is aware of the significance ofT-helpercell levels. David is unwilling to see a physician fora follow-up exam to learn more about his healthstatus. After further discussion with his counselor,David says it is enough to know he is infected, andhe is not ready to deal further with his infection: "Idon't want somebody to do a (T-helper cell) test onme and tell me I'm sick and I'm going to die."

Counseling Intervention

Recognize the source and significance of Dav­id's fear. Because follow-up care can reveal David'sstageof infection, and may even show that he hasanAlDS diagnosis, David may fear discovering that heis sicker than he feels or thinks he is.

Begin by assuring David that laboratory tests,including T-helper cell counts, are only a generalindicator of immune status, and that a T-helper cellcount, whether it is 500 or SO, does not mean that aperson is necessarily going to become symptomat­ic. Help David see a T-helpercell count not as a testdelivering a death sentence, but as a tool he can useto evaluate the overall status of his immune system,gain greater control over his health and determinewhen to begin appropriate interventions.

Describe H1V infection as a condition spanninga wide spectrum, from early to more advancedstages that may stretch over many years. T-helpercell counts usually decline gradually, and it is usu­ally several years after after being infected before aperson's T-helpercell count falls toa point at whichthe immune system is severely suppressed. Re-

mind David that HN antibody and T-helper celltest results do not reveal when he was infected.

Ask David about his health and energy level,and teU him these are important indicators of hisgeneral health. Help David see the importance ofusing his own feelings about his health in combina­tion with laboratory tests, such as T-hclpcr cellcounts, and clinical signs of infection. Beyond this,describe the concept of health care for HfV infec­tion and provide medical referrals so that Davidhas this knowledge when he is ready to considermedical care.

Stress that a great deal about the managementof I-llV disease has been learned since the begin­ning of the epidemic, and the trend is to begintreatment at earlier stages of infection. With T­helper cell testing., David can have the chance tolearn if he is at a stage in which he can benefit fromintervention. if he is unwilling to seek health careat this time, accept this decision, and state the valueofaccepting the knowledgeofhis infection until heis ready to seek follow-up care.

Suggest that even without seeking aT-helpercell count, David can seek follow-up counseling ormedical care. By doing this, he can talk with aclinician or counselor about his thoughts and con­cerns regarding his health while being monitoredfordinicalsignsofdisease. Provide him with refer­rals, and advise him to return to the test site if heneeds more information. Strongly encourage Davidto talk. with other people who are infected with I-llV,and encotmlge him to involve others, such as friendsor family in his decision-making. David needs sup-­port to make the decision to seek fotlow-up care; thecounselor and other individuals can provide that

which antiviral treatment will bemost effective. At a later stage ofinfection, such treatments may beless successful at keeping a personhealthy.

• "How do I know when tostart taking AZToranotherd rug?"

Therapy with AZT or anotherantiviral is often recommendedwhena person'sT-helpercellcountfalls below 500. It is at this pointthat a person's immune system issuppressed to the level where

treatment is beneficial. However,not all physicians agree with therecommendation to useAnwhenT-helpercell counts fall below500.Clients can consult with their phy­sicians for further direction.

• ''What is the virus doing tomy immune system right now?"

The virus may be relativelyinactive and may remain this wayindefinitely. Or, it may be active,and therefore weakening the im­mune system and eliminating T-

helper cells. Such activity will beundetectable if there are no clini­cal signs of disease, or if a personfeels healthy. The effect of HIV onthe immune system can be deter­mined by measuring T-helper cellcounts, or other laboratory mark­ers of progression.

In many cases, clients may askthese questions about the virusonly after the test counseling ses­sion. Provide referrals who willlater be able to answer questions.

PAGE 8 PERSPECTIVES

TEST YOURSELF

1.Truear False:T-helpercell countsare considered the most valuablelaboratory marker in predictingshort-tenn health risk for a personwith HIV.

2. Antiviral treatment is generallyrecommended when T-he1per cellcounts fall below what level? a)1,000, b) SO, c) 500, d) none of theabove.

3. T-helpercell tests can show vary­ing results for what reasons a) cellcountsfluctuatenaturallyeachday,b) laboratories measure results dif­ferently, c) both a and b can occur, d)none of the above.

4. True or False: A study found thatbeta-2 microglobulin levels fell, in­dicating a reduced risk of HIV pro­gression, when people began tak­ingAll.

5. Drug treatments such as AZfarebelieved to have what effect on T­helper cell levels? a) they boost lev­els for an extended period, b) theycause levels to consistently falI, c)they have no effect.

6.TrueoTFalse: FallingT-helpercellcounts definitively mean a personwill soon become symptomatic.

7. True or False: Most people withHlV have nonnal T-helper cell lev­els for several years after infection.

8. The following are used as mark·erg of HIV disease progression: a)p24antigen, b) beta-2microglobulin,c) n€Optenn, d) all of the above.

QUESTIONS FORDISCUSSION

• Clients may resist health careafter receiving test results becauseknowledge of infection and health sta­tusisoverwhelming. Howcanacoun­selor present a discussion of follow­up care and T-helper cells for theseclients? How can a counselor knowwhether such information is over­whelming?

• Markers of infection other thanT-helper cells are important, but maynot be required discussion for post­test counseling sessions. When mighta discussion of these tests be useful?How might these other markers bepresented?

• How much information shouldantibody test counselors provideabout markers of infection? Are theresome antibody positive clients forwhom it might be more useful not totalk about markers?

• In what ways can counselorshelp clients see the value in seekingfollow-up medical care and lab tests?

• Because the new definition ofAIDS proposed by the Centers forDiseaseControl is based in part on T­helper cell counts, clients may fearthey wi]J qualify for an AIDS diagno­sis at the time they test antibody pos­itive. How can counselors help clientsview this possibility as being a stagein the spectrum of HIV infection, in­stead of as a sign that they will soonbecome ill?

Answers to "Test Yourself"

1. True. Vihile //01 an absolute predictor, T­he/per cells are collsidered the mosl valu­able laboratory marker.

2. C. Trealment witlt antiuirals is generallyrecommended when a person's T-helpercell cormt falls below 500.

3. C. Tests for T-helpercells call show vary­ing results for both of these reasons.

4. True. A study folilld decreased beta-2microglobulin levels, illdicaling a reducedrisk of HJV progression, in people whobegml taking AZT.

5. A. AZTmId otherantivirals elm cause T­helpercells 10 it/creasefor aperiod that mayextend for several years.

6. False. While T-helper cell carmls are pre­dictors of disease progression, they do notdelennine that a person will develop seri­ous ill/lesS.

7. True. MallY people continue for severalyears with IlOrmal levels of T-helper cells.

8. D. All of I/lese are mnrkers of disease pro­gression.

How to Use PERSPECTIVES:

PERSPECTIVES is designedas an easy-to-read educationalresource for antibody test counsel­ors and other health professionals.Each issue explores a single topicwith a ~Research Update" andan "Implications for Counseling­section.

The Research Update reviewsrecent research related tothetopic.In Implications for Counseling, theresearch is applied to the counsel­ing session, and a case study ispresented. PERSPECTIVES alsoincludes two sets of questions toconsider yourself or discuss withothers.

Volume 2, Number 4

Department of Health services, Office of A!DS,P.O. Box 942732. Sacramenlo, CA 94234. (916)445-0553; AIDS Health Project, Box 0884. SanFrancisco, CA 94143, (415) 476-6430.

HIV Counselor PERSPECTIVES

PERSPECTIVES is an educational publication of the Calilor­nia Department of Health SelVices, Ollice of AIDS, and is wrillenand produced by the AIDS Health Project of the University ofCalifornia San Francisco. Reprint permission is granted, providedacknowledgment is given to the Department of Health Services.

Information in PERSPECTIVES is based In large part on inputfrom antibody test counselors and other health professionals.Among those who had a significant influence on thiS issue are:Mitct1ell Katz, Kelly Butler, Alex Taylor, Carol Norman and Chris­topher Ham.

This Issue of PERSPECTIVES published in August 1992.

PERSPECTIVES is printed on recycled paper.

Director, AIDS Health Project: James W. Dilley. MD.

Writer and Editor, PERSPECTIVES: John Tlghe.

CUnlcal Consultants: JD Benson, MFCC; MarciaQuackenbush, MFCC: Jaklyn Brookman, MFCC.

Publications Manager: Robert Marks.

Editorial Research: Clare Poller.

Technical Production: Leslie Samuels; Joseph Wilson.

Administrative Support: Roger Scroggs. ~_

AIDSHEALTHPROJECT