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Treatment Question
Jun 5, 2006

Hi Dr. Wohl, thanks for answering so many questions. I am curious about one thing in particular in regards to the timing of starting treatment. I've read that you believe the latent reservoirs of HIV are probably not doing too much harm to the body...if I read your posts correctly, it seems as though you believe the real harm that HIV inflicts on the body occurs while people are waiting to start therapy, since active HIV is basically swimming around in the body, damaging all sorts of healthy cells. If that's true, then why wait to start HIV therapy for years? If one could try and eliminate as much of the virus swimming around in the body as possible as early as possible, it seems as though you could possibly prevent more cells from being damaged and, thus, offset some damage to the body. I know that a latent reservoir is established very early on in infection, but I suppose I'm wondering if, aside from the latent reservoir, anything can be done to limit the amount of damage from active virulent particles that are doing nasty things to healthy cells (immune cells along with other types of cells) early on in the disease. If we know that the virus is probably doing all sorts of destructive things, why not start therapy as soon as possible instead of waiting years for the CD4 to hit an undesirable number or percentage...it seems like the virus can do a wealth of harm to the body in those years. I think I'm a little confused...your thoughts would be much appreciated. Thanks.

Response from Dr. Wohl

Your question is at the heart of the on going debate on when to start HIV therapy. There are few infectious diseases where treatment is delayed until things get worse. In the case of HIV infection, the rationale behind waiting was based on the side effects of the meds, the potential to build resistance and run out of options and data that demonstrated no difference in AIDS or death (over 3 years) if HIV meds were started at a CD4 of 350 or above.

As HIV treatment has gotten more potent, less toxic and more resistant to resistance many are asking the same question you are posting. Indeed, many clinicians have started to recommend therapy earlier in the course of HIV (CD4 cell creep) and I suspect we will see more movement in that direction.

But, to clarify, I am not sure that there is loads of damage to the body going on when the CD4 cell count is very high. However, I think the viral load may be much more important and that lots of virus could be doing harm. In such cases I am not tending to recommend therapy even if the CD4 cell count is well above 350.

I hope that helps!

DW



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