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do meds work on asymptomatic patients? (When to start)
May 18, 2003

do meds work on aymptomatic patients? as of late april my cd4 count was 815 and my viral load is 3,124. would my cd4 go up and my viral load go down if i were to start kaletra/combivir meds? i'm so confused on this issue. i thought the drugs help protect good cells. would it not be more advantageous to begin meds now while i'm aympotomatic? please help.

dave

Response from Dr. Young

Thank you for your question.

Medications do "work" on asymptomatic patients-- that is to say that they can be expected to drop viral load and prevent decline of CD4 cells.

Your CD4 absolute count is definately in the normal range, though from a theoretical standpoint, we know (and can measure) alterations in cellular immune function long before CD4 absolute counts reach the current treatment threshold of 350 cells. For example, we can see decreases in CD4% and increases in CD8 cell counts; there is a decline in the T-cell repetoir and decreases in the CD4/CD8 cell ratios (implying a net decline in immune function). This perhaps can be measured by the increases in so-called minor complications, like sinusitis, bronchitis or thrush, even among persons with CD4 counts as high as 500.

Indeed, this was the basis of the "hit hard and early" strategy that had dominated treatment guidelines up until very recently. What has caused a reassessment of when to start is the realization that for many persons, optimal adherence was difficult, if not impossible-- causing increased rates of treatment failure and drug resistance. Additionally, earlier treatment means that persons will be exposed to medications for a greater duration of time, increasing the possibility of side effects, or worse, toxicity.

So, while we might theoretically want to treat all persons with HIV at all times in an ideal world, real world therapy with current (and imperfect) medications means that we must balance the likelihood of benefit with the risk of complications.

In practical 2003 terms, we make the balance between these issues with a statement that tends to defer treatment for the asymptomatic, chronically infected person until CD4 counts are lower (current guidelines say 350) or viral loads are higher (higher than 55,000 copies/mL). These are merely guidelines, and there are so many individual circumstances that govern individual clinical decisions that many persons who meet these criteria might wait longer and others will initiate treatment quite early. The key is understanding all of the potential risks and benefits, in order to make the most informed decision possible.



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