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do I start?
Aug 13, 2005

Hi, I've been infected for about 3 years. My CD4 has always been low (in the 300's to very high 200's - no trend either way). But my VL has also been very low, usually under 10k. Any suggestions as to why my CD4 is so low, this early, especially in the presence of a relatively low VL. I have no symptoms, other than minor fatigue and have always lived a healthy lifestyle and been healthy. I am not in a hurry to start meds but I don't want to start meds too late either. It seems that so many new treatment options are on the horizon and I was hoping that I might be able to use HAART as a last resort. I read with interest the results of the therapeutic vaccine studies and was hoping that I could hold out for something like that. Is that unrealistic? I'm also concerned that since my VL is already low, will HAART make that much difference in my CD4 count? My doc is a major hit hard hit early advocate so I question his opinion. Am I doing harm by waiting? Lastly, I know what the gov't guidelines say but I would like to know what your opinion is based on your clinical experience - what would you do if you were me? Thanks so much for your time.

Response from Dr. Pierone

The conceptual model that suggests CD4 count rate of decline is simply related to viral load not entirely accurate and does not account for a situation like yours. In fact, it is not that unusual to have a relatively low CD4 count in spite of a relatively low viral load. One potential explanation for why your CD4 count has been low may have to do with immune activation. A greater degree of immune activation may lead to CD4 cells proliferation and subsequent destruction by HIV. Although this theory is being examined by researchers, we really don't have a way to measure immune activation for clinical practice.

I have also read the therapeutic vaccine research with great interest, but the pace of this work will be hard to gauge. I know that there are multiple phase I therapeutic vaccine trials underway and several that are entering phase II. The treatment action group (TAG) recently published an experimental pipeline update that is well worth reading.

I doubt that you are doing yourself harm by waiting, but don't know that for sure. Because the newer HIV medications are better, I find myself inching closer to the hit hard, hit early camp, but have some reservations. One of the reasons that our team is actively participating in the SMART study is to help answer this crucial question about timing of antiretroviral therapy. One thing that we have observed in this trial is that patients on early therapy do very well, but so do those on deferred treatment (to less than 250 CD4 cells).

The "what would you do if you were me" question is a trick question and allows doctors to skillfully inject their own bias into treatment decisions that should be patient centered. Looking to doctors as potential health role models is fraught with risks. With that caveat, personally I would be considering a therapeutic vaccine trial. One final point though is that at some of the therapeutic vaccine trials are looking at patients on HAART with controlled virus. The plan would be to vaccinate, then stop HAART and see how long it takes for virus to come back in the vaccine arm versus placebo.

Thanks for posting and good luck with your decision.



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