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very early meds?
Aug 21, 2007

In the past month I found out that I was HIV positive. My CD4 count was around 680 and my viral load was like 11,000.

While I was happy that the numbers were good, I still felt a little unsettled. My doctor explained that usually people start on medication when their count gets down around 200-300. My unease with that prospect is that by delaying the medication, I feel as though I'm just idly sitting back and letting the virus destroy my cells. Then, once it gets to a more dangerously low level, I'll use the medicine to maintain that level. But this is my question: instead of sitting back and letting the virus take its course, why not start the medication now so that I could, presumably, maintain the 600-700 count that I have now? I understand that there are two risks that must be balanced here: the risk of missing medications & the risk of side effects of the medications. Are those the only reasons I would delay treatment? And, if so, am I giving too little weight to the seriousness of potential side effects?

As a sidenote, I read an article last week about some new research that was conducted in which certain medications were actually able to raise HIV patients' CD4 count. I'd be interested in your thoughts on that.

Response from Dr. Wohl

Your reasoning is right on the money. There are few conditions in medicine where we wait until things get worse before starting therapy. Can you imagine if a doctor told a patient with breast cancer to come back when the lump grew a few more centimeters?

In HIV we do wait because, as you mention, we are concerned that if we treat too early there could be long term side effects as well as a risk of drug resistance if adherence falters.

Bu, what if we had the perfect HIV regimen - no side effects and resistant to resistance. Then we would have no excuse to not treat from the point of detection of HIV infection regardless of CD4. We do not have the ideal HIV drug but we are closer to it than we once were. Therefore, many feel we should start treatment at CD4 cell counts higher than 300 or 350. Not surprisingly we are seeing more clinicians initiating HIV therapy earlier even though there aren't the studies proving conclusively that this is the best approach.

In your case whether to start treatment must be based on your and your doctor's understanding of the data and your general sense of what is best. 680 is a fairly high CD4 cell count. Perhaps wait a few months and see what is going on with your counts. A downward trend may be enough to convince your doc and you that starting meds is right for you. Otherwise, you may wish to run with the herd and choose the moment to strike.

DW



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