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When to begin treatment
Dec 31, 2008

As you can imagine, I have had lots questions post my recent diagnosis and after being a big believer in the power of the internet, in this case, I find that I'm begining to hate it. There just seem to be so many contradicting views as to when and how best to treat HIV, the various effects/side effects and the impact on life expectancy. Not being a doctor I'm confused as to the science behind all these arguments and I dont want to be second guessing people that know better than I do. My doctors view was that, I could live a healthy normal life for a while and that it would be best to stay off treatment for as long as possible because the treatments themselves are strong and effectively poison you over a period. Yet there are many arguments to the contary that treatment should be started as soon as diagnosed. My CD4 count was 498 and my viral load was found to be 500,000.Can you help me to understand why the many opposing views and what you would advise.

Response from Dr. McGowan

I understand your frustration. HIV is one of the only infections that. once identified, we don't always treat right away even though we have effective medications. There are several reasons for this: 1) We cannot cure HIV. The virus' genes can stay inserted into some of the resting cells of the immune system for decades. So a decision to start treatment means a long-term commitment. 2) HIV can develop resistance to medications and treatment requires high levels of adherence that may be hard to maintain over time. To conter this, our newer treatments are much stronger and easier to take, so this argument is still valid but less compelling. 3) Earlier treatment means longer exposure to medications and potentially more toxicity over time. Again, our newer meds are much easier to tolerate, so this argument is getting a bit weaker. Also we have evidence that delaying treatment may be worse than starting sooner. When to start treatment has been a bit of a moving target. We had been burned by treatment toxicities in the late 1990s, but that is more rare now. Most people are looking at earlier treatments...above 350 CD4 count. This may be changed farely soon to 500 CD4 count. It is a decision that you and your health care provider need to make together. Good luck, Joe



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