The AIDS Epidemic in San Francisco: The Response of Community Physicians, 1981-1984, Vol. I

Current Diagnosis and Prediction of Disease Progression

Hughes

Do you put people with ARC in a slightly different category, or do they all have AIDS in your mind?

Campbell

Well, when I put down a diagnosis for HIV infection I'll put down viral load da da da, CD4 da da da, history this, this, this, this. Like I might say, "HIV infection, asymptomatic, low viral load, CD4 500." Such a person is far from AIDS. Or I would say, "HIV infection, viral load 1 million, CD4's twenty, history, Pneumocystis, M. [Mycobacterium] avium, CMV." That's somebody who's on the extreme other end of the HIV disease/AIDS spectrum. The disease is staged by the CD4 number, the viral load, and all the specific illnesses which a patient has had. A typical ARC patient may be described like this: "HIV infection, viral load high, let's say 100,000, CD4 count 300, history: hairy leukoplakia, recurrent diarrhea." However, this is not a classical AIDS-defining illness. So that's the way I do it.

Hughes

So in your mind, the disease is a spectrum.

Campbell

It's a spectrum. You think of it in the dimension of the viral load, the strength of the immune system, the specific infections the person has had, and maybe also their ability to function. Because you might get somebody who has a high viral

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low and very few CD4 cells, who's had Pneumocystis but is still working full-time, and let's say Karnofsky score ninety, ninety-five. I don't always put the Karnofsky score down, but I think somebody who's making a strict definition of a particular person would include the Karnofsky, the viral load, the CD4's, and the specific AIDS-defining illnesses.

Hughes

So this is a very mutable system too, isn't it? Because of all these scientific parameters that you now are able to obtain, you can place people along a spectrum, but with the understanding that when you go back six months from now, they very well may be in a different place on that spectrum. So none of this is static?

Campbell

None of it is static, but I think that these days when we see people, it's really fairly cut and dried. We know who's apt to be getting ill fairly soon, and we know who's not. If somebody has, let's say, a stable 200 CD4 count and, let's say, a viral load of 5,000, which is relatively low, and they're tolerating a bunch of antiretroviral drugs, and they don't have anything else which is AIDS-defining, we know that we're just going to see that person every three months for a routine visit, and they're not going to be getting sick in the near future.

But if you see somebody whose viral load has gone from, let's say, 10,000 to 500,000, and they're having little fevers, and they've had thrush for the first time, you know that something is going to happen soon, or they've become intolerant or resistant to a particular antiretroviral drug.

Hughes

That really is pretty predictable? People really do tend to progress in that fashion?

Campbell

Yes, and I think you get a lot of predictability through the viral load. If you take into consideration the viral load and the CD4's, plus just the way the person feels, you can get tremendous predictability as to who is going to be around a year or two or longer.

Hughes

This predictability became possible with the ability to detect accurately the viral load?

Campbell

I think there was predictability on the basis of the CD4 cells long ago, and predictability on the basis of what specific opportunistic infections somebody might have had. But then in August 1994, right after the Tokyo meeting [of the International Conference on AIDS], we started doing these viral loads. That added a much sharper dimension to somebody's profile, as to whether they were going to do well or not. Some

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people run very low CD4 numbers but have very low viral loads; those people just tend to do much better than persons with low CD4 counts and higher viral loads.

Hughes

What you're describing is a syndrome that is being defined increasingly more exactly because of technological advances. Right?

Campbell

Yes.

About this text
Courtesy of Regional Oral History Office, University of California, Berkeley
http://content.cdlib.org/view?docId=kt6580067h&brand=oac4
Title: The AIDS Epidemic in San Francisco: The Response of Community Physicians, 1981-1984, Vol. I
By:  Sally Smith Hughes
Date: 1996
Contributing Institution: Regional Oral History Office, University of California, Berkeley
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