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Why wait to start meds?
Jul 26, 2005

I was diagnosed last September after being very ill. My doctor said I was newly infected and going through zero conversion? Initially my VL was in the millions. It has since gone down to 88000 with CD4 465. As it has been over 6 months should I expect that my viral load has taken a high set point? Although my CD4 count is still OK should I not consider starting treatment sooner rather than later?

Response from Dr. Pierone

Someone diagnosed with primary HIV infection at or shortly after seroconversion may have an opportunity to intervene with immediate therapy. If they choose to do so, this intervention may prevent the widespread early immune damage related to HIV and possibly lower the set point of HIV and favorably alter long-term outcomes even when medications are stopped. This is by no means proven, but some pilot studies have shown promising and intriguing results. One of the crucial determinants may be starting HAART within weeks of seroconversion. Based on the 6 months interval since seroconversion, these studies would not apply to your situation.

That said, we honestly don't know when and how to best treat HIV infection. These are the choices:

1. Treat everyone with HIV infection as soon as they are diagnosed and never stop. 2. Wait until the CD4 count drops below a low threshold of 200 cells, start therapy and never stop. 3. Wait until the CD4 count drops below an intermediate threshold of 350 cells, start therapy, and never stop. 4. Wait until the CD4 count drops below some a high range threshold (500?, 700? - your choice), start therapy and never stop. 5. Start therapy at any of the previous CD4 count levels, but discontinue medications at some point in order to limit drug-related side effects. Then restart at some CD4 count threshold with the plan to stop again in the future when CD4 counts achieves some higher level or when side effects supervene (start, stop, start, stop, etc). Clearly, choice 5 has many possible permutations and could get quite complicated. Also, there are few data supporting a STI strategy, and thus it is not included in the treatment guidelines.

Since we don't know what is best, and since guideline committees typically seek a middle-ground compromise, option 3 is right in the middle of 1-5 and this is what is recommended. Will this change? Most certainly it will. There is a growing movement towards earlier treatment since the medications are less toxic. There is also continued interest in STI strategies, so stay tuned. Here is a link to the DHHS guidelines if you want a detailed analysis of treatment considerations. Hope this helps and best of luck to you.

little break

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