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5 wks aftr infection too late to start meds?
Jul 31, 2002

This is a great resource and you guys are great humanitarians to answer all these questions for free! THANK YOU!

I have read lots on your website (and others too) about starting on anti-retroviral meds during acute infection (i.e., the "flu-like" symptoms that lead to seroconversion). As I understand it, the new "bottom line" belief is that if it's within "a few weeks" after becoming hiv-infected, then one would be wise to start on meds. But "a few months" after the infecting event is too late, such that one should view himself as having a "chronic infection" at that point -- and in the usual situation should wait until CD4 count is between 200 and 350 to start the meds.

I know how hard it is to draw lines in this area where the studies are not yet conclusive, but I find this a very hard decision to make in my situation and would like your input.

Here's my specific situation: I believe I was infected with HIV 36 days ago. Blood drawn 6 days ago tested NEGATIVE for the antibody. My acute infection is going away, with some swelling in the lymph nodes remaining, and still a great deal of fatigue. Rash is all but gone now.

I am reluctant to prematurely commit to taking potentially toxic drugs, but will gladly do so if it will improve and extend my life on a net basis. But there are warnings on your site and elsewhere about scary side effects, the risk of wearing out certain classes of drugs too early, promoting drug-resistance, etc. In light of all the promising drugs you guys tell us are on the way -- to my simple mind, it seems to make sense to wait, preserve all my options until I hit CD4 of 350ish, and live a drug-free life for the next few years, and hope that you smart guys hit a less toxic home-run for me during that time.

(1) Please explain in terms I can understand why you (and other eminent doctors) believe I would be giving up something important if I choose to wait for the CD4 decline before starting on drugs? What exactly would I be giving up? And...

(2) In my situation -- do you think I am still within the window where starting now would likely make an important difference in the length and NET QUALITY of my life? What would you do if you were in my shoes?

THANK YOU!

Response from Dr. Wohl

Hi-

Thanks for your important question. You are correct, evidence is accumulating that starting HIV therapy during a period of time referred to as primary or acute infection can have lasting benefits. The idea here is that if the virus can be controlled early then the parts immune system that are some of the 'first responders' directed against HIV can be preserved. Without HIV treatment these cells are the first to bear the brunt of HIV. Saving these cells seems to be important as the few persons who live long term with undectectable HIV and stable normal CD4 cell counts without HIV therapy (so-called long-term non-progressors) tend to have preserved more of this type of immune response than those who are more rapid progressors.

Other advantages of early therapy may be the limiting of the spread of HIV to sanctuaries in the body where HIV can persist and where HIV medications may not get to readily late on. Also, studies of structured treatment interruptions have shown the greatest promise of this approach in the setting of acute HIV infection with an apparent lowering of the viral set point - the level HIV in the blood settles at after acute infection.

So overall, there seems to be much benefit to early treatment. IF problems arise during therapy it can also be adjusted or even stopped. Its a big step taking HIV therapy but you may have a unique opportunity to positively change the course of your HIV infection.

Studies that have treated people with acute HIV infection have done so at various time points after infection with some even treating just after seroconversion (when the ELISA and Western Blot become positive). As your HIV antibody test is still negative you are still in the acute infection window.

Depending on where you live, I would immediately try to find out who in your area is doing any clinical studies of therapy during primary HIV infection. If you are in the Southern US or have trouble locating a center near you, email me at wohl@med.unc.edu. There are centers in North Carolina and Atlanta actively recruiting for this type of research.

Also, for the record, we do not do this for free. I am glad you find it worthwhile. - DW



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