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Why Did My Doctor Wait?
Jun 9, 2009

I read with continuing interest the ongoing debate about when to start meds. But now the subject matter has hit home.

I tested positive a year and a half ago, and at that time had a viral load of 5,200 and tcell count of 550. I was ready to start meds right then, but my doctor (who is an HIV specialist) said no, not yet. Six or seven months later, I was basically at the same numbers. (tcells 520, viral load actually lower at 5000.) I still did not start meds, upon dr's recommendation.

I just got back from getting my latest numbers -- my tcells have plummeted to 92, although my viral load is 5850 (which as I understand is still relatively low.)

I have now started Atripla, as well as an antiobiotic to keep me from getting pneumonia.

How much of a disaster is this? Why didn't my doctor want to start me earlier? How worse is my prognosis and life expectancy now that I am starting meds at tcells 92, rather than a year and a half earlier ago when I was still in the 500's? I've read that starting treatment when your tcells are lower means a lesser life expectancy and less successful treatment potential. I can't get over being upset for not insisting on starting on meds a year and a half ago. How much additonal damage has been done to my immune system, compared to if I had started a year or more earlier? Thank you for your help -- I am agonizing over not having insisted.

Response from Dr. McGowan

Thank you for your question.

You had experienced an abnormally rapid drop in CD4 based on your viral load. That number should certainly be verified (also check the CD4% to see if that has been stable- that will help show if this is a drop just in the CD4s- as with HIV infection- or a more general drop in your white blood cells which may be due to something else).

That being said, it emphasizes the importance of close monitoring of CD4 counts since trends can change. Some things that may account for a sudden drop in CD4 count may be the presence of an acute illness (such as a viral infection, or bacterial infections like pneumonia or tuberculosis which could happen with good T cells), a troposim switch of the virus (which means the way the virus attaches to and enters the cell, which can evolve so that the virus can attack CD4 cells more broadly and have a higher blood level). or getting re-infected with a strain of HIV that may be harder for your body to fight off. Some of the studies on response to treatment in people with low CD4 counts are muddied by the fact that (unlike you) many people wait to start treatment till their CD4 count is low because they don't believe in the benefit of treatment or they don't take care of themselves, or have mental illness or substance use problems. It is naturally harder for them to turn around and start using their meds the right way. You, on the other hand, should do well and get your viral load fuly suppressed. Generally when the CD4 count drops so fast, it may also recover fast because the flux of cells is so high. It is true that the best time to start is not known, and that everyone acts differently, so the best thing is to monitor the counts closely and base the decision of when to start on sound information. I do believe you will do well and should not have any long-term decrease in your benefit of treatment.

Best, Joe

Very concerned about rise in viral load.
Swine flu

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