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Hard and early V Wait and see
Oct 12, 2002

Dear docs

Do you have any insight on the issue of when to start treatment.Reports from europe suggest that hitting the virus early may not benefit the long term suppression of hiv but can use up drugs that could be used later.As you all seem pretty clued up on these matters could you shed some light on this issue. Many thanks

Response from Dr. Wohl

When is the optimal time to start HIV therapy has become the question of the hour in HIV treatment circles. We debate it, write editorials about it, look at data from patients treated early and those treated late, convene expert panels that arrive at the different conclusions, we do many things to try to get to the bottom of this but mostly we hedge. No one, and I mean no one, really knows when it is best to start and clearly no 'answer' will fit all situations.

In general, as we started to see more toxicities associated with therapy, more treatment failures and evidence that HAART would not eradicate the virus from every nook and cranny in most patient's life times, we collectively started to treat people later.

Some very imperfect but helpful data from large groups of treated patients seem to indicate that delaying therapy initiation until the CD4 cell count hits around 200-350 is not dangerous. But, we need longer-term studies to fully understand the competing risks of early treatment (more side effects and resistance) and delaying treatment (more opportunistic conditions and uncontrolled HIV replication). As newer drugs with less toxicities and more convenient dosing become available, we may see the pendulum swing back to hit hard hit early. In the meantime, we must do what we can with the information we have and foremost try as best we can to do that which Hippocrates commanded and that is to 'do no harm'. DW



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