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Initiating Treatment because of devloping neuropathy in feet
Dec 11, 2007

Dear Doctors. Thank you for the great work you all do on this site and giving the many of us in countries without ready access to expert opinions a forum to raise our questions.

I seroconverted in December 2006 (best estimate). My current first reading CD4+ count is 469 and my VL is 24900. I can feel the beginning of what I can only assume is the onset of neuropathy in my feet. I know I should not assume my own diagnosis and will have my own "diagnosis" validated with a neurologist soon. However, and assuming I am correct, the prospect of this condition worsening has me very concerned and wondering whether it would not be advisable to begin treatment sooner (i.e. prior to current guideline recommendations of CD4+ being <350)rather than later, in order to prevent the neuropathy from getting wrose. I will have a second set of blood tests in January but my doctor does not anticipate that my numbers will substantially worsen and that based purely on this fact (probable stable CD4 and VL being anticipated) I would probably not need to go on medication for a while yet.

Do you think the risk of worsening neuropathy justifies the earlier commencement of medication and if so do you anticpate the nueoropathy symptoms to abate with ARV treatment? Would it be better to delay treatment and see whether the neuropathy abates on its own? Does neuropathy inevitably worsen? Will treatment reverse (allow my body to reverse) the nerve damage caused by the virus in the current infected environement?

I would obviously want to delay starting treatment for as long as possible, but I do not want to risk irreversible nerve damage either. What would you do if you were in my (aching) shoes?

Response from Dr. Young

Thanks for your post.

If the diagnosis of peripheral neuropathy ("distal symmetric sensory neuropathy") is confirmed and there is no other compelling reason (like diabetes or syphilis) for the symptoms, I would recommend starting treatment.

Since the peripheral neuropathy (assuming the above is correct) is caused by uncontrolled HIV, starting HIV treatment is really the only way to reverse the disease. Indeed, in all of the focus on CD4 counts as the factor in deciding when to start treatment, it is very important to remember that all treatment guidelines (including the recently released DHHS guidelines) recommend treatment for symptomatic HIV disease, irrespective of CD4 or viral load levels.

HIV neuropathy is a real hassle and sometimes does not fully resolve, even with effective HIV treatment. For this reason, is I were in your shoes, I wouldn't be waiting too long after diagnostic confirmation to treat. Indeed, waiting to start actually increases the risk of developing neuropathy, even among those persons who do not have neuropathy before treatment.

Best of health, BY



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