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Hit hard, Hit Fast or Hit Hard and wait
Nov 30, 2004

I tested positive about a month ago, and beleive I have been infected for close to 1 year. I dont even know my lab tests yet, but will soon be going to see a specialist in Ann Arbor, MI. Without taking lab results into consideration, can you please give me your opinion or research on what it the better way to go for starting medications. Is it, hit hard and hit fast, as in starting on meds as soon as possible, or hit hard but wait for a persons cd4 count to lower to 300? What are the pros and cons of each? I would like to know this before I go to Ann Arbor next week. Thank you


Response from Dr. Pierone

We don't know how best to treat HIV infection.

Hitting early and hard brings the virus under control fairly easily with current medications, but the cumulative adverse events related to the medications may outweigh the benefits of suppressing viral replication. Also, if adherence is not excellent, drug resistant virus may develop and this can limit future treatment options because of cross-resistance. Another benefit of early treatment is reduction in infectivity of the person with undetectable viral load.

Waiting until the CD4 count drops is the standard of care based on all authoritative guidelines. There are disagreements in when to start and what to use as one would expect. The chance of complications from HIV is very low until the CD4 count drops below 200 so it appears to be safe to wait. Those that begin with lower counts appear to reconstitute the immune system quite well. There may be some qualitative and quantitative differences in immune function between those that start treatment early and late, but these do not seem to be clinically meaningful. Deferring therapy also eliminates the risk of developing drug resistant virus and drug toxicity.

The SMART study is well underway (but still recruiting) and compares early versus later treatment. Hopefully this trial will help us answer this crucial question.

Slow CD4 count increase
symptoms related to HIV infection

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