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When to Start?
Jan 7, 2005

Because of my recent medical history and the fact that I am currently stationed overseas (Jerusalem), am curious as to when to start treatment. I will be back in Washington DC to see my doctors there in January for a three week period, and am planning to move back to DC in the spring -- around April. Should I start in January? Or wait?

History: In July was in DC and tested negative.

Was also in Texas at that time, where apparently contracted typhus (rocky mountain spotted fever), diagnosed in mid-August back in Israel. Treated with doxycycline (100 mg, 2x daily, 10 days).

Late August was stabbed while in Tel Aviv -- 4 cm stab wound of abdomen, laceration of liver with intra-abdominal hemorrage. Had exploratory lapartomy and hemostasis of liver laceration. Spent week in trauma unit at hospital and three weeks convalescing in hotel.

Late September suffered typhus relapse. Again prescribed doxycycline (100 mg, 2x daily, this time for 15 days).

Was in DC in October, saw my regular doctor as well as surgeon to review recovery. Was tested for HIV; this time positive.

In retrospect, initial typhus symptoms may have been HIV conversion, under assumption I was infected in late July - either too recent for July test to pick up, or immediately thereafter. (I did not receive blood in surgery).

October 12 test results (performed in Washington): CD4 = 528; T4/T8 ratio = 42.9%; viral load = 231,237.

November 14 test results (performed in Tel Aviv): CD4 = 266; T4/T8 ratio = 37.3%; viral load = 188,788.

December 14 test results (performed in Tel Aviv): CD4 = 546; T4/T8 ratio = 52.9%; viral load = 102,698.

Will repeat tests in mid-Jan with my doctors there, in effort to establish baseline that is not "corrupted" by recentness of conversion (which I understand can lead to spikes and erratic initial results) or from use of different labs.

Am 50 years old, otherwise in good health. Liver function and other blood counts are all back in normal ranges, having been slightly off during period of acute typhus and liver surgery recovery.

Given my situation, what would you advise? Under assumption that January confirms Decemeber's numbers -- start then? Or wait 3 months until after I've moved back to DC?

Response from Dr. Pierone

The current treatment guidelines use a cut-off of less than 350 CD4 count and based on your recent infection and these numbers you can wait and see how things go. The recent infection complicates things because you may not have reached a viral load "set point" yet. The relatively high viral load is of some concern, but the declining trend is very positive and another reason to sit tight and get some more readings. The recent trauma, surgery, and possible rickettsial infection may also be impacting the readings. Let us know how things turn out. Good luck.



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