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early treatment at CROI
Apr 15, 2007

recently I listened to a CROI podcast here at Thebody.com from one expert who suggested the 350 treatment start guideline will certainly change towards earlier start, but didn't say what is early start!

My personal doctor have also been to CROI and during our last discussion he seemed in favor of early treatment as well. My question was how early is considered early treatment? My doctors' reply was 500 CD4....I'm currently at 488 CD4 and 20,000VL. He said we'll talk about it during my next visit due in 2 weeks. Is it worth starting that early? I'm healthy albeit for headaches that started few months ago and infrequent fatigue that I would rather relate to my untreated depression (I hate SSRIs and won't take them again!) and I face my depression with some sports since a few weeks.

your answer is very important for me.

All the best and respect for your outstanding service for people like me.

Response from Dr. Wohl

I think there is a slow but steady stream of information that is building a case for the earlier start of HIV therapy. The current threshold of 350 T-cells for the start of HIV meds is a completely invented number. We used to start HIV treatment at a T cell count of 500. A few studies then looked back at large numbers of patients starting HIV therapy at different T cell counts and found that those who initiated HIV meds at a count below 200 did worse than those starting higher counts. The number between 500 and 200 is ?? Right, 350. Astrophysical science, this is not.

The problem is that it is really hard to have a study conclude that starting meds at a higher T cell count is better. Given the outcome of interest is progression to AIDS, it would take thousands of patients and many years to tell whether one group starting therapy early would do better or worse than another group starting late.

Recent studies suggest that having HIV replicate unchecked in the body for long periods of time is not a good thing. People interupting HIV treatment have had more problems with HIV and complications such as liver, kidney and heart problems. Other studies show that the risk of cancers, liver disease and heart disease is higher among those with lower T cell counts - even among those with counts between 200 and 500.

At this point, few are suggesting a wholesale revision of the 'start at 350' doctrine. However, many of us are inching up our threshold for treatment initiation. As therapies become easier to take, the temptation to start earlier grows. This movement is based more on gestalt and inference right now than hard science. So, what you should do depends on your own research as well as your trust in your provider and his judgment.

DW



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