Hi Doctor,

First of all, thanks for all your wonderful advice, you do a great service. My question is that I have recently found out I'm HIV + and had my viral load and CD4 counts done.

My viral load is 36,200 and CD4 is 561 (29%). I have read so many different positions on starting treatment, but the one that sticks in my mind is to start when the viral load is at 55,000 copies or higher.

Should I follow that recommendation, or should I just allow my CD4's to remain high (if they do) and wait until I'm at 350 CD4? I know that one needs a crystal ball to predict what might happen since there are no long term studies that determine the outcome potential of early vs. delayed treatment, but what's your intuition tell you?

Thanks

Thanks for your post. I'm very sorry to hear about your recent diagnosis.

In general, most experts will delay the initiation of HIV treatments for a while-- current guidelines (as you refer to) don't recommend starting until CD4s are around 350. This recommendation isn't just a crystal ball, but is based on observational studies of thousands of patients that show that there is little measurable benefit for starting therapy with higher CD4s. Not a statement etched in stone and clearly the history of HIV treatments records plenty of times when we've been misinformed. I think that a more qualitative (rather than quantitative) way of thinking of this is that there are some risks and costs involved with treatment-- with high CD4 counts, there is little benefit (though perhaps theoretical ones) whereas with lower CD4 counts there is potential benefit. There is some emerging evidence that waiting too long places patients at increased (perhaps irreversible) risk of developing HIV complications, such as lipodystrophy. Balancing all these competing issues crystalizes into a watershed of decisions that the guidelines capture as a threshold to start.

For any one individual, there are differences in the factors that come to influence this decision. We live in an era of individualized therapies-- individualized treatment regimens and treatment strategies, but in general, I agree with the current guidelines with regard to when to start. Invest the time to learn about your options and discuss them with your healthcare provider.

Good luck, thanks for reading. BY