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Time to Start Treatment?

Aug 25, 2004

I had my 3 month appointment with my HIV doctor today. I was diagnosed 7/12/2002 (just after my 22nd birthday, though I know my infection date to be 4/18/2002 for certain), and have thus far avoided treatment. My CD4 % has slowly dropped from 27 to 23%, and has been hovering between 20 and 22% for the last year and a half now. My Viral load has been all over the map from as high as287,000 to as "little as" 29,500, with absolutely no consistency between visits. My CD4 has been up and down, and for the second in a row, has been down, from 399 to 320. So, I've hit below the magic "350" threshold, and I'm now considering treatment options. The doc seems to think that since my CD4 percentage is still at 20% and my total lymphocyte was only 1600, it may not be so unusual that my CD4 absolute count would have gone down. However, I'm not so convinced. I've requested another set of labs, which I will go in for on Saturday, and if my CD4 absolute is still below 350, I want to start treatment. My question is two parts: as a doctor, would you also recommend more labs showing results below 350, and go more by the CD4%, would you have started treatment earlier, or recommend it now? Also, if I start treatment next month, what therapy would you recommend. My doctor mentioned a new combo pill of a two drug, once daily treatment, that could be taken in conjunction with Sustiva, for a 2 pill, once a day treatment. I want something powerful, yet manageable, as I fully understand the importance of adherance.

At 24yo, and postive for two years, I am hoping my numbers to rebound quickly (hopefully a CD4% up to 35-40% with CD4 absolute between 640-1100, since I started with 792.)

Sincerly, Painfully Pondering in Michigan...

Response from Dr. Young

Dear Painfully,

Thanks for your post.

To answer your questions, since there is so much variability in HIV lab tests, I do like to see two sets of labs that confirm the need to initiate treatment (assuming that you're asymptomatic). I do tend to recommend consideration of starting treatment when the CD4% is repeatedly below 20%, since this typically correlates with a absolute count of about 300.

As for what to start, the two new combo pills (Epzicom --abacavir/3TC and Truvada--tenofovir/FTC) combined with efavirenz (Sustiva, Stocrin) should both prove to be very simple to take, well tolerated (in general) and very potent. I'd talk to your doctor about the relative pros and cons of each and how they would fit into your lifestyle. Rest assured that if you're able to adhere to any of the contemporary first-line treatments that we'd expect about a 200 cell CD4 increase in the first year, and continued rises thereafter.

Good luck, thanks for reading. BY

Very High VL

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