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Follow-up to First Labs, Should I Start Meds
Mar 12, 2010

Dr. McGowan,

I was just reading a question to you from someone positive for 2 years with CD4 around 400 and 17%. I've noticed that people who are diagnosed right after infection seem to start meds much earlier. I've been poz about 9 years and not on meds yet. I'm sure my numbers looked very bad right after infection. Isn't it true right after infection, numbers can look really bad (even like AIDS), but the immune system is still in very good shape. I know some people progress very fast, however.

I'm wondering if the questioner would be considered to be out of the acute infection stage at 2 years, and the CD4 of 400 would probably be the highest it is going to get not on meds? I have debates everyday about starting meds. Since my CD4 has been stable around 800, my doc keeps saying there is no rush. However, I keep reading about the unseen damage HIV is doing. I've read on Dr. Gallant's site how he thinks most all HIVers should be on meds and said a viral load near 30,000 is not good day after day. Mine has bounced around so much--14,000, 6,000, 27,000. It is a huge decision weighing the possible issues with meds vs having a good CD4 but vl in 20k's. I know we probably aren't going to get some definitive study saying what is best for a few more years. I would just hate to wonder down the road why I waited around if I should get sick with something. I've read people with high CD4s get lymphomas, KS, and other OI's. If there weren't issues with meds, then experts would recommend starting right away. I've also read the "hit hard and early" approach may be responsible for more resistance issues. It said many docs now say "hit later and carefully."

Thank you so much for all the great info!

Response from Dr. McGowan

Thank you for your post.

You have really summed up the issue very well. We are in a transition period in our thoughts about when to treat. We are learning that having virus growing in the body unchecked for years can do damage to various organs, including the heart and brain. It may be that once the initial insult has occurred, even if you later get the virus suppressed. The risk of drug resistance would come if people get tired of taking their meds and miss alot of doses. Based on your post, I do not think this would be an isue for you. The newer meds are better tolerated than in the past. I think the pendulum is swinging toward earlier treatment. Afterall there are very few infections that we know can cause significant illness that we have effective treatment for but we don't treat. The argument probably should be to treat unless there is a compelling reason not to.

Thanks, Joe



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