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When to start
Feb 10, 2005

I have been HIV positive for 3 years and my CD4 count has dropped from 454 with a VL of 58000 to a CD4 count of 364 and a VL of 68,500. Have the guidelines for starting treatment changed over the last year or so. I recall that the recommendation was to start when your VL was above 55000 and your CD4 count dropped to 250? I do feel some fatigue and have a consistent dry cough. Other then those symtoms I feel great! Do you think it is time for me to start taking meds? Could I already be resistant to some medications based on the strain of HIV? Do you ever do resistence testing prior to starting medication? Your Web site is a wonderful source of information! Please let me know how to proceed.

Response from Dr. Young

Thanks for your post and nice words.

First off, current US treatment guidelines suggest considering treatment in persons with CD4 counts below 350 and/or with viral loads that are in excess of 100,000. In every individual circumstance, it would be important for the patient and doctor to weigh the pros and cons of initiating treatment. In my practice, it's important that the patient be willing and able to adhere to a treatment and that they fully understand this balance between potential benefit (usually great) and potential risk (usually low).

With your current CD4 count and HIV viral load, I don't think that there is a strong indication to start medications. That said, it still is important to understand and diagnose the cause(s) of your fatigue and cough. Make sure that you mention these symptoms to your doctor.

As for drug resistance, it is standard of care in our office to obtain drug resistance testing in all treatment-naive patients-- this is because about 10% of our chronically-infected, treatment naive patients have some evidence of drug resistance; usually non-nucleoside resistance, but other patterns too. There's no way for you or your doctor to know if you might have resistance without running a resistance test. These tests may not pick up every instance of resistance, so it remains important once HIV medications are started, that the virologic performance (ie, viral load response) is monitored closely-- for those patients who do not have adequate initial responses (but are fully adherent), the possibility of hidden drug resistance should be considered.

I hope this helps. Good luck, BY

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