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Early start of treatment
Jan 30, 2010

Hi, I'm pos for 3,5 years. Average CD4 around 450, Viral load between 1000 and 3000. So all pretty excellent from a physical point of view.

My specialist and I are considering an early start of treatment. His view is that treatment is far easier than before, sideeffects with first-line are normally none to minor - and most importantly I would pretty much be non infectious to sexual partners any more. Physicially there is not real reason however given the numbers.

I'm however not sure. My main reason for an early start would be the contagiousness for one, but also to lower the viral load. AFAIK - viral loads are considered harmful in the long run from a number 20.000 to 50.000 and higher. I've been averaging on 2.000 and less for the last 3 years.

So I have to choose between the lesser of two evils : 1. Be somewhat contagious and take the psychological burden - and live with a low Viral load but no meds 2. Bring viral load to undetectable via meds and live with the long+short term sideeffects and the potential damage the meds will do.

I know studies are being conducted to compare starting at 500 barrier vs the 350 barrier - but all still very uncertain when it comes to results.

I've been thinking about this one for months now. What would your recommend ?

Bert

Response from Dr. McGowan

Bert,

The new US guidelines from the DHHS agree with your doctor (http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf). Starting treatment is now recommended when CD4 counts are below 500. I have also moved in that direction as long as a person is ready to start and commit to treatment. You have stated the arguments well for early treatment: preservation of the immune system, reduced risk of transmission, easier-less toxic treatments, and suppressing the virus. The big "black box" in the argument is what damage having unchecked virus will cause in the body. At these CD4 counts AIDS is not really the issue. What has been found is that having HIV can set up a person for early heart, kidney, liver and brain disease. This is likely related to direct effects of the virus and, perhaps most important, the inflammation (or "immune activation") that the virus causes. Although your viral load is low your immune system may be very stimulated by the virus and react strongly to keep it in check, that inflammation over years may come at a price. In fact your situation (low viral load with relatively good CD4 count) is the one where there is least consensus on the best approach. I think the evidence is moving in favor of treatment. The START trial may help answer this, but the results will not be available for a few years and won't help us decide in the short term.

Best, Joe



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