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When to start treatment - just exposed to HIV

Jun 25, 2003

I was just exposed to HIV in the past two months and subsequently tested positive. My T-cell count is 452 and my viral load is 770,000. My doctor said that since my viral load is above 35,000 I should start treatment (Combivir and Sustiva). I've only had one viral load test and blood count test; and friends have said I really don't have a proper baseline and should not start drug treatment yet. They said that since I just converted I am most likely spiking because my body does not know how to respond to HIV yet. They recommend a second set of test to see what direction the counts are going - I may not need treatment for several months or years. Are my friends correct? Do you have any other recommendations?

Response from Dr. Pierone

Your situation is one of the most vexing in HIV medicine and we simply don't have the answers. There is some evidence that people diagnosed with very early HIV infection may benefit from immediate treatment.

The rationale is that by treating early one can prevent widespread entrenchment of HIV in body reservoirs and favorably impact the long-term outcome. There may also be preservation or possibly enhancement of immune response to HIV with early treatment. The little data showing successful structured treatment interruptions has been in persons treated during very early infection. There may well be a significant opportunity lost in not treating immediately for these reasons.

The counter argument is the one your friends are proposing - wait and see, determine the virus "set point". They are right in that often viral load comes down fairly quickly and CD4 cells will likely be above the traditional threshold for treatment of about 350 for years.

So if you do decide on treatment now, how long? Again, we just dont have hard answers. So we try to choose a prudent and cautious approach based on current understanding of the information available. What I recommend to my patients in your situation is to get another pre-treatment set of labs (along with resistance testing) and then go on immediate treatment. Re-evaluate at 6-12 months and make a decision at that time about continuing treatment based on tolerability, adherence, and virologic and immunologic response.

Whatever you decide, best of luck.

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