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Hit Hard and Hit Early
May 21, 2005

Dear Dr. Young, thank you for all the time you invest in our questions. My question is the following:

I read that by starting therapy when the CD 4 count is relatively healthy(normal), the functioning of the immune system can be preserved and therefore maintain or correct the ability of the immune system to fight HIV. If this is true, could it also be beneficial to start early by delaying the onset of drug resistance, or can drug resistance occur at anytime regardless of when therapy is started? It could also be said that starting early could minimize the chance of experiencing side effects. I am writing this question because treatment was offered by my doctor. My first labs were:CD4-274 and viral load 53,100. I am completely asymptomatic and would like to delay the onset of AIDS as much as possible. Thank you Dr. Young, any response will be extremely helpful.

Response from Dr. Young

Thanks for your post.

I don't think that in your situation that you have to debate the hit-hard-hit-early debate.

With a CD4 count of 275 and viral load in the 50,000-range, if I were your doctor, I would recommend starting treatment in the near future. This statement is particularly strong, given your sentiment that you'd like to delay the onset of any AIDS-related complications.

You are right in so much as avoiding resistance is indeed a worthy goal (though early treatment initiation with suboptimal adherence actually increases, not decreases the likelihood of resistance). In this respect, the use of first-line boosted PIs, especially Kaletra and Lexiva (fosamprenavir), have been shown to dramatically reduce the amount of drug resistance among the minority of patients that experience treatment failure.

You're also correct in the general sense that it's probably better to preserve immune function rather than to build it up from the basement. That said, newest treatment combos have been shown to be very effective in restoring immune health, even among persons who start treatment with very low CD4 counts.

I hope that you find this helpful.

Good luck and good health, BY



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