What is your personal recommendation for a person newly infected - start meds or wait? Are the meds going to work for a specific individual a certain length of time no matter if it's early or late in the disease? ie., will drugs 1,2, and 3 go undetectable for, say, 18 months, for Person A whether they've been infected 4 months or 4 years? If this is too variable a question, can you at least generally tell the time vs. treatment recommendations?

Thanks a lot, your help is greatly appreciated.

Well... we've reviewed this issue a few times in the recent past - so I invite you to browse the questions of the past few months for other versions of this issue. But here is another version of it.

Recently there is a hint of more data to support that, at least in terms of controlling HIV for the long term - the sooner one starts meds the better. This is based on two issues - one is the apparently narrow window just after seroconversion, during which there are cells still present that might help control HIV in a way that is seen in people who are called "long term slow progressors". If treatment is started during that window period (now estimated as within 6 months after initial exposure to HIV) - then treatment may save these cells, and in turn these cells might contribute to controlling HIV over the long term, even without the need for meds at some point.

Second, however, is a newer observation. A group in Switzerland suggested that the ability to more fully suppress HIV with our current meds may also be associated with starting at a CD4 count over 500, as compared to those below 500. What they reported was that the ability for treatment to get the viral load to not just below 50 copies, but down to below 3 copies, was seen more often in those who started treatment with a CD4 count over 500. And we currently understand that one reason our meds "fail" is that HIV can grow despite them - so the lower the viral load, the longer the result. So getting below 3 should last longer than between 4 and 50. So - starting sooner might allow whatever meds to last much longer - perhaps as long as we need them to.

But there is always a pro... and a con - for starting early, like with a CD4 count over 500. The major "cons" are that this person is at the least immediate risk for any problems associated with HIV infection - and is thus at least need to take meds to stay well for a while. And so the burden of taking meds, finding that discipline, is sometimes harder when there is less immediate risk. And we must note that over the years we still learn not only about the long term benefits of treatment, but the long term complications and side effects of some of these meds. And we have learned that starting below 500 cells is certainly associated with significant benefit. It is still just a prediction that starting early will triumph over starting later... and so much depends on the person, the pill taking discipline, and the side effect versus benefit ratio.

And there will likely never be a better answer to this dilemma. Each person will need to weigh in their own minds the pros and cons - and pick an approach.

The only somewhat more recent twist to starting early is the reminder that treatment can be interrupted in someone who finds they need to stop for some reason - starting meds is not a one way road. People can stop - and HIV does not acquire resistance from stopping. This issue has been misunderstood - it is erratic med use that leads to resistance. But if someone chooses to stop meds - for a side effect for example - then if HIV was suppressed on the meds, it will stay sensitive to them as we withdraw the meds and allow HIV to return. And so the meds that were useful in that combo and stay useful in some future combination. So someone can start and not feel "trapped" by that decision - it can be a trial period. For as long as you choose.

Hope that helps. CC