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A warning about high viral loads
Dec 28, 2003

Hi From a recent article in Treatment Update 139 www.catie.ca they warn about high viral loads. In the study they suggest if your viral loads are in excess of 100K you are at increased risk of death. New research from the British Columbia Centre for Excellence in HIV/AIDS suggests that people with HIV/AIDS (PHAs) who have high viral loads may be in need of closer monitoring and perhaps more potent therapy. My question is when should I start meds and what meds as the situation does apply to me. Seroconversion Feb 2003, Apr/03 Vl.425K CD4 820; May/03 Vl. 265K CD4 970; July/03 Vl. 176K CD4 690; Oct/03 VL. 290K CD4 820. I have been targetting the CD4 350 level as the place to start meds. In view of this study what is your opinion?

Response from Dr. Pierone

Those with high viral loads progress more rapidly than those with low viral loads towards AIDS and death in untreated HIV infection. However, with potent antiretroviral therapy, there is not much difference in ability to control HIV replication between the two groups. With less potent regimens like unboosted protease inhibitors and triple nukes there are lower rates of virologic control with high viral loads. We don't have evidence that people with high viral load need to begin treatment at higher CD4 counts, but this is an important question to answer.

In cohort studies, some people with high viral loads have high viral loads because they have failed therapy or stopped treatment for one reason or another. It is not surprising that in observational studies of this nature that there would be a higher rate of death in those with high viral loads. This does not really apply to your situation in which you have good CD4 cell counts despite the high viral load.

A CD4 count of 350 is a reasonable point at which to start therapy based on our current knowledge. My personal bias is to offer treatment at an earlier point for people with higher viral loads but I admit this is not grounded in expert guidelines but based rather on my sense that HIV medications are getting better and the pendulum may have gone too far in favor of deferred treatment. Hope this helps. GP



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