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long term positive not on meds yet, now what? (WHEN TO START TREATMENT)
Feb 24, 2008

Are there any studies or recommendations for people who have been infected for long term, not on meds, yet still respectable numbers? I was infected in or before 1989, some key numbers are (1992) cd4 488 % 21; (1998) cd4 462 % 23 vl 3576 (2007) cd4 312 % 12.5 vl 7000. My numbers have fluctuated over the years with the worse occurring in 2004 (sept)cd4 261 % 13.2 vl 22.8k; (dec) cd4 349 % 19 vl 46.7k. (maybe it was Bush being re-appointed as president). ANyway, my Dr is now pressuring me because of the new "guidelines". But I feel a number of say 350 is relevant differently if a person takes 5 years to get there , versus someone who takes almost 20 years to get there. Any ideas?

Response from Dr. Frascino

Hi,

"Studies or recommendations" for this situation? Well, clinical "studies" would not be feasible as there would be far too many variables to control to get any meaningful results. "Recommendations" would be published guidelines, which in and of themselves have been modified a number of times over the past several decades as we've learned more about the natural history of HIV disease and developed better diagnostic tools and therapeutic agents. In general I would not agree with your premise concerning the rate of decline of absolutely CD4 cells. The reason to measure CD4-cell counts is to determine your degree of immune competence or, said another way, your degree of immune deficiency. The lower your CD4s go, the less immune integrity you have to fight off opportunistic infections and malignancies. So if you were to drop to a CD4 count of 200 within 3 years or 13 years, your risk of getting PCP (pneumocystis carinii pneumonia) would still be the same once you hit that level.

The exact optimal time to begin antiretroviral medications remains a difficult question for many reasons. For most infectious diseases the optimal time to begin treatment would be as soon as one knows one's infected. This would be true for HIV as well if we had either (1) a cure or (2) safe, effective medications that could be taken for extremely long periods of time with negative consequences (side effects, toxicities, development of drug resistance, etc.). However, since we don't have either #1 or #2, we are stuck with trying to balance risk and benefit. One of the reasons the guidelines advanced from 200-250 to 350 is that we now have better, safer and more convenient HIV medications from which to construct potent combination regimens. You can read much more about all of this in the archives and on its related links throughout this site. Personally I agree with the move to begin treatment earlier and would encourage you to strongly consider starting therapy.

Good luck.

Dr. Bob


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