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progressing long term non-progressor: when to start treatment?
Oct 14, 2007

I've been positive for probably 24 years. I tested positive in 1986 but my last unsafe sex before that was in 1983. I am not on treatment. My CD4 cells have slowly dropped some over the years but seem to be staying in the upper 500s for the last several years. My viral load was consistently under 15,000 until this year. 3 months ago and 6 months ago it was 46000 and 48000, respectively. My CD4 counts are still steady in the upper 500 range.

I was on AZT monotherapy for about 6 years as part of a study from 1990 to 1995.

I would say I'm pretty healthy. But the recent viral load increase concerns me. As does the greater potential to transmit the virus.

So my questions are: when should I start treatment (now?), and what should my first treatment regimen be, given that I was on AZT monotherapy for several years, several years ago?

Response from Dr. Pierone

The formal recommendations are to start HAART when the CD4+ lymphocyte count drops below 350. However, there is a movement among some HIV thought leaders suggesting that treatment should be started sooner. There is some logic to this notion since the newer medications are less toxic than the older ones and this fact shifts the risk benefit analysis towards earlier treatment. However, the data favoring earlier treatment are limited. In this cynical age one could make the argument that since most HIV thought leaders consult for the pharmaceutical industry of course they would look kindly on earlier initiation of HIV medications. But skepticism aside, this is their genuine unbiased opinion and clearly has come about because of the availability of much better initial therapy. In fact, when I informally ask my colleagues in HIV medicine what they would personally do if they had HIV infection and a CD4+ lymphocyte count above 500, the great majority would start treatment straight away. For the record, I would too.

Back to your situation: If you choose to start therapy, Atripla (Viread+Emtriva+Sustiva) would likely be effective and it is hard to argue with a one pill at bedtime regimen.

Thanks for posting and good luck!



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