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Hello again Dr Bob - karate girl here again!
Feb 20, 2003

Hello Dr Bob,

Maybe you don't remember me - I'm the one competes in karate and initially wrote in after being diagnosed for a couple of months asking if it is ok to keep training to the level I do. Anyway, 6 months later, I have finished a 6 month course of meds taken to attempt to preserve my immunity as much as possible. One month on from being off them again, my labs were CD4's - 1070, and viral load - 140. So I'm not in bad shape at the moment. My question is - what do you think about the cyclical method with hiv meds - ie: I have 6 months off, then 6 months on, etc for a couple of cycles? I have heard about it, but am unsure what to do. My doctor is expecting me to just stay off meds fullstop until I need them again (though I don't want my CD4s to drop below 500 before I go back on). My doctor is not an hiv-only specialist - there aren't really any in my area, as hiv is not very common in this part of the UK. Just wanted your advice really. Second part of my question - I am not anaemic in the true sense of the word, but my iron stores are always on the low side. Any reasons why this might be happening and yet never turning into fullblown anaemia? My doctor appears to not have the patience to answer all my questions!

Thanks in advance! Jasmine xxx

Response from Dr. Frascino

Hey Jasmine,

". . . Not in bad shape at the moment???" Considering how much you work out, I'll bet you're in excellent shape indeed! And your HIV disease matches your great physical condition - CD4 1070 and viral load 140 one month out from your 6 months of treatment is great news!

So what to do now is the question. 6 months on, 6 months off? Stay off 'til CD4 drops to 500 or some other number? Restart if viral load goes up to a certain number? The answer is that no one really knows. There are a variety of clinical trials going on at this very moment trying to answer this very question. We heard updates on a variety of these studies at the HIV meetings in Boston this week. The verdict is still out. The strategy of taking meds very early in the course of HIV disease to preserve immunity seems to be sound. Strategic treatment interruptions for folks chronically infected appears much less successful and may even be harmful. The consensus of opinion now (which I agree with, by the way) is to treat recently acquired HIV infection for 6 months and then monitor closely off therapy with CD4 and viral load tests every 3 months. If your CD4 count drops and/or viral load rises significantly and consistently, then you (and your AIDS specialist) need to decide whether therapy should be restarted, and what meds to consider. The reason I'm not giving you a specific recommendation is because the guidelines are changing rapidly. The advice we would give someone today might be quite different 3, 6, or 12 months from now. I'd anticipate you may not need to consider treatment options for several (perhaps many) years. By then, hopefully we will have the results of the current clinical trials to definitively answer the question of which approach is best!

It's probably worth searching for an AIDS specialist, even if you need to travel a bit to find one. You'll only need to see him or her periodically, perhaps once a year. However, when and if you need to make a decision about restarting meds, the specialist's advice will be invaluable. They will advise about new meds (5 currently in the pipeline), immune-based strategies (including strategic treatment interruptions or therapeutic vaccines), and assess the fitness and resistance profile of your specific virus. Experience is the key here.

Second question: Iron stores can be low due to a variety of conditions, including inadequate dietary intake or absorption. Ask your doctor if an iron supplement is warranted. Also keep an eye on your hemoglobin level. If it falls below normal (Hgb of 12 g/dL for women), contact your doctor for an evaluation.

Third issue: Doctors who don't have "patience" to answer questions shouldn't have "patients" at all! Consider finding a more cooperative physician!

Keep working out and keep me posted if problems or questions arise.

Stay well, Jasmine.

Dr. Bob

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