Oct 11, 2006
Hi doctor Bob, i'm curious: ive been positive for 3 years VL=37k, cd4=550, cd4%=41%. my lymph nodes in my neck have been swollen for the last 3 years which i think is due to HIV killing CD4 cells and they go there when they die.
My counts are still good and i'm not on meds. but is there good reason to get on meds now rather than waiting? That is, even if my counts stay the same, if i start meds 3 years from now, will my body have less "stuff" available to work with in 3 years because HIV has killed so many cd4's?
Another way of asking this is: does my body have a finite number of cd4's it can make in its life or is it practically limitless? And is the impact on dendritic cells also a cause for concern if i'm not on meds?
Please let me know what you know about this?
Response from Dr. Frascino
Although I would enjoy the challenge of explaining the complete story of CD4 and dendritic cells, in reality it's highly complex and well beyond the scope and purpose of this forum. Consequently, I'll skip to the practical portion of your question: when's the best time to start therapy? The truthful answer is that we don't know or perhaps a better reply would be the answer keeps changing. Our recommendations have evolved as we learned more about HIV pathogenesis and also the antiretroviral drugs used to treat HIV disease. Hypothetically (and simplistically), HIV is a germ and in most cases as soon as we know someone is infected with a germ, we would treat them to cure the infection. Unfortunately HIV doesn't work that way. The medications we have so far do not eradicate the virus (cure the infection), but rather merely suppress viral replication. It is true that suppressing viral replication significantly impedes HIV-induced CD4 destruction and therefore progressive immune deficiency as well. So common sense would suggest we should still treat as soon as possible, right? Well that would be the case, except that current anti-HIV drugs all have significant short- and long-term toxicities and side effects. Added to this is the fact that HIV often can develop resistance to HIV medications, ultimately rendering them useless. Therefore we must balance the risk of side effects/toxicities and drug resistance against the benefits of decreasing viral replication and preserving or improving immune function (CD4 counts). One other complicating factor is that we are developing new drugs year by year that each has their own specific qualities (side effects, toxicities, tendency to develop resistance, potency, efficacy, etc.). Consequently our when's-the-best-time-to-start recommendations are certainly "a work in progress." At the present time, using our currently available drugs, we suggest starting HAART (highly active antiretroviral therapy) when the CD4 count drops consistently into the 250-350 range. As always, I would encourage you to work closely with an HIV/AIDS specialist. The issue of when to start is complex and must take into account many factors and variables. As better, less toxic, drugs become available, our current recommendations will most likely continue to change. For now, I would suggest you hold off on starting HAART, but continue to monitor your CD4 count and viral load every three months.
Just another thankyou
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