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When to start? Over 500 CD4 cells...
Jul 11, 2008

Dear Dr DeJesus,

I have read with great interest your answer to the question:

"High viral load, High CD4 count Jun 12, 2008"

I mostly agree and understand what you say and recommend. I've been positive for over a year and planing to start meds before my cd4 count goes down to 350.

However, you seem to recomment to start as soon as possible, even with a CD4 count over 500.

I know there are good reason to start earlier rather than later but there are also risks.

Side effects of course, our bodies might benefit from staying off meds a little longer. Another problem is the chance of running out of options: let's say my CD4 count is 500, I start Atripla and cannot tollerate it, I switch to some other meds and develop resistance in 2 years. Now, my CD4 count would have been over 350 anyway but starting meds early I have burnt two regimes... and the pipelines of new meds on trial is not as promising as it was 4 years ago.

I'm just thinking loud, and would appreciate your comment on this.

Thanks!

Louis

Response from Dr. DeJesus

Louis, I appreciate your interest on this topic and thanks for posting your thoughts and questions.

I want to make clear that current guidelines recommend initiation of therapy for the most part for patients with CD4 < 350. My point was that there is already evidence of benefits for patients that initiate medications even at higher CD4 counts. I will not recommend for everyone to start at CD4 above 500, but certainly there are some patients that could benefit from an earlier initiation of treatment.

Given that the new drugs are so well tolerated with minimal toxicities, it is certainly conceivable the idea to start earlier in well educated patients that have evidence of progressive disease, even if their CD4 count remains elevated. For example, a well educated and motivated patient that has a persistently declining CD4, now approaching 500, with an elevated HIV viral load. Sometimes, there are patients that are very anxious about having HIV infection, and they feel better on treatment, knowing that they are doing something about it; or sometimes, we encounter patients with HIV-negative partners, and they want to reduce their viral load to prevent or minimize transmission to others.

For a new patient starting therapy today, who takes its meds as instructed, it is very difficult to "run-out-of options". Even if you are not able to tolerate the initial regimen, and it needs to be changed, the likelihood is that you will be able to take another simple regimen without problem.

Remember, medications do not fail patients, patients fail medications. By that meaning that if a patient is taking medications, and the treatment is working for more than 6 months (undetectable viral load), the likelihood is that that treatment will continue to work, perhaps indefinitely for as long as the patient takes the medication with good adherence. The medications usually do not just stop working after a few years. Also, for the most part, the patient cannot develop resistance if the viral load is undetectable.



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