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Should I start taking Med's or just wait
Dec 12, 2003

Hello, I am a 27 year old male and I have a question, I test postive about three years ago. My CD4 count is between 550 - 900 and my VL have been between 800-1200. I have seen about three different doctors. and they told me I should not take MED's until my CD4 drop to 200 or less. I have had only one problem, thrush on my tongue, but I noticed when I stop smoking cigarettes it went away. my question is should I start taking MED's or just wait. I feel health, I work out about three time a week and take B-12 complex and a muti vitman everday. my doctor said I my just be a slow progresser.Am I taking a risk by not taking med's . I am scared of the MED's I have so many bad things happen to people start on the MEd's

Response from Dr. Frascino


We do not know the exact best time to start potent antiretroviral therapy (HAART). The guidelines recommending when to start therapy have changed several times over the years. The decision is complicated by several key factors:

1. Potential drug toxicity, particularly long-term drug toxicity.

2. Adherence problems. HAART requires a very high level of adherence. If doses of medication are missed, the virus can mutate and become resistant to the drugs. Since we only have a limited number of drugs to choose from, this can reduce your options for subsequent effective regimens.

3. Immune reconstitution and potential irreversible immune deficiency. HVI slowly destroys immune function. This can be seen in the progressive decrease in CD4 cells. If the CD4 count falls below 200, we know statistically people are at greater risk for opportunistic infections, and there appears to be less effective immune restoration even if HAART is started.

OK, so what does all this mean for you? Well, there are several sets of guidelines currently published. The strictest guidelines would advise not starting HAART until your CD4 count drops below 200, because that is when one becomes more susceptible to opportunistic infections and when one still sees reasonable good immune reconstitution when HAART is started. Other guidelines indicate HAART should be considered when the CD4 cell count is a bit higher in the 300-350 range. The thought here is that immune reconstitution may be more complete when starting therapy at this level of CD4 cells. There is also a concern that waiting until the CD4 cells drop below 200 may be placing patients at some degree of risk that is unnecessary. As always, the potential benefits of starting therapy decreasing viral replication and improving CD4 cell counts must be balanced against the potential risks of drug side effects/toxicities.

Presently, your CD4 count is in a very safe range of 550-900, and your viral load is low (800-1200). You've been positive for at least three years. At this point, I believe the potential downside risk of beginning HAART inconvenience and potential short and long-term side effects/toxicities would outweigh any potential benefit. You feel healthy and work out regularly. You definitely need to stay off cigarettes, not only to control your thrush, but also for your overall good health. This is the single most important thing you can do to maintain your good health at this moment.

I would also suggest you continue to monitor your CD4 cell counts and viral load every three-four months. My personal opinion would be to recommend consideration of HAART when the CD4 count falls consistently into the 300-350 range. Let's hope your physician is correct and that you are indeed a slow progressor, and may not need to make this decision for a very long, long time. Let's also hope that when and if you have to make that decision that the treatment options are better than what we have to choose from today.

Good luck.

Dr. Bob

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