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Inflammation And The Organs
May 9, 2010

I've noticed you've gotten several questions lately about when to start meds. I know this isn't unusual as you get that question probably the most. Starting meds is a huge decision for most people--especially if you have a high CD4 and low viral load. I know many feel it is not good to allow HIV to go unchecked. We weigh that against what we don't know about long-term use of meds. We ask ourselves, "Could I go another 2, 5, or 10 years without needing meds?"

I've maintained good CD4 counts and low viral loads, so far. I worry about the damage to my brain and other organs you and others talk about. I know the kidneys are usually checked by looking at BUN and Creatatine. Are there tests/labs we should be having done? Urine test to check for protein? Stress-tests to check the heart? Even if we have good lipids, could there be issues? Should we have more sophisticated tests done for the kidneys and liver? About the brain, I guess there is nothing that can be checked except if we started noticing cognitive issues developing. What about the eyes and hearing? I recently read something about hearing loss caused by HIV.

It can all drive a person crazy. In one of those questions to you, the person talked about turning yellow from the Reyataz. I've heard that is nothing to worry about. Then, he mentioned a kidney stone. It does make many us wonder what is worse--the meds with good numbers or the inflammation and unseen damage not on meds with those good numbers.

I really appreciate all you and the others do on here. I know you can't say for sure what is best and that study may give us more insight. I guess I'm wondering if you'd suggest having more sophisticated tests done in HIVers going 10 years and still not on meds? Would the tests tell us much?

Response from Dr. McGowan

Thanks for your very thoughtful question. You have really hit on the current state of affairs. Most people now would be comfortable with the US DHHS Guidelines to start antiretrovirals if the CD4 count gets below 500, but ...what to do above that? The expert panel was split 50-50 in recommending treatment essentially for all regardless of the CD4 and those who felt less strongly. So, if treatment is to be deferred, how do we assess the effects of the virus if not by the CD4 count? That is your question and we have no good answer. It is certainly a good idea to check kidney function, urine protein, lipids (cholesterol, triglycerides), routine cancer screening (anal PAP for men, cervical and anal PAP for women, along with age appropriate screenings: colonoscopy/mammogram, protate screening), tests for cognition (memory tests which can be done in the office), vitamin D and bone density screening. We don't know if HIV meds will help reverse effects once they occur, but screening seems reasonable. Studies have been conflicting about which may be the best test for immune activation or "biomarkers" for heart and brain disease, such as C-reactive protein, IL-6, amyloid and others. People with many risk factors for heart disease (such as strong family history, high blood pressure, diabetes, older age), or cancer may elect to start antiretroviral treatment sooner. The bottom line is that starting treatment at a high CD4 count is an individual decision and depends on the balance of risk/benefit each person feels.

Thanks, Joe

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