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Now or Later?
Dec 13, 2003

Today's the one-week anniversary of my testing positive. A million questions, of course, but chief among them is when to start treatment. I know there's been a lot of controversy over the years over whether to hit it hard from the start or wait until the numbers take a nosedive, and I'm wondering if this excerpt from November 20th's Washington Post accurately sums up the current thinking:

"... Nevertheless, Gordin said, the new findings will reinforce the current trend to start antiretroviral therapy later in the course of infection -- when CD4-cell counts are in the 300 to 400 range. In the late 1990s, many HIV-infected people with near-normal counts were being prescribed the drugs. Now, there is growing evidence that holding off for a while does no permanent harm..."

Apologies if this is an "old-news" question, but I'm only one week into my crash course in HIV. As much background and analysis as you have time to include will be greatly appreciated. Thanks.

Response from Dr. Pierone

Your question is not at all old, but rather one of the fundamental unanswered questions in HIV medicine. When ought treatment be commenced for HIV infection? The best answer based on available data is in the range of 200 to 350 CD4 cells (for asymptomatic persons). Had we entirely safe and inexpensive medications, we would surely recommend earlier treatment.

But even if we had better medications, we would still have the looming issue of drug resistance. If one takes blood pressure medications sporadically, they will still work later on. The Achilles heel of contemporary HIV treatment is that non-adherence leads often leads to viral resistance which makes subsequent treatment much more complicated. So we really need safe and inexpensive therapy that does not lead to drug resistance, a tall order indeed.

For a detailed analysis of HIV treatment issues the DHHS guidelines are very informative. Good luck!



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