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Arguments needed to Start Treatment

Aug 31, 2014

Dear Dr. Young, Need your advice on pros/cons of starting treatment earlier rather than later. I got tested poz on Jun 1st. Viral load was 84.5k - dropped to 47k on July 1st. My CD4 count was 674. The Drs here in Greece say that they will not consider treatment until it drops under 500 (or even 350!!!) in order to start meds. But they said we can talk about it in my next appointment in October. My resistance tests showed resistance to Efavirenz & Nevirapine - which I guess means that I also cannot take Atripla, Sustiva and Viramune, right? I suppose they could prescribe Stribild. Their counter argumentation is (1) all the side-effects of the drugs; (2) that they sooner you start the more time the virus has to eventually become resistant to the drug; (3) that it is better for the body to fight the disease on its own as long as it can and then reinforce it. Note that for the last 2-3 months I have very wet night sweats - bed linen get white salt-stains and have to change them every couple of nights. Also dry/red skin on the face/ around nose and above the eyes will not go away for over 2 months now. Your guidance is greatly appreciated! Regards!

Response from Dr. Young

Hello and thanks for posting.

In my opinion, too many people, including doctors and government agencies focus too much attention on CD4 counts and ignore widely agreed upon recommendations that about conditions that are also indicators for treatments. Your doctors (and all HIV care providers) should consider treatment for people with CD4 counts above 500. All international agencies suggest so.

According to the World Health Organization's 2014 treatment guidelines, ART should be started if CD4 counts are below 500 OR if any of the following conditions exisit: (1) all pregnant and breastfeeding women; (2) individuals with TB disease; (3) individuals with hepatitis B coinfection with evidence of severe liver disease and (4) individuals in magnetic relationship (HIV poz/neg).

If you fall into one of these categories (especially common is #4), treatment is indicated, "regardless of WHO clinical stage or CD4 cell count".

Here in the US, as well as in several other countries, including Brazil, treatment initiation is not guided by CD4 cell count, rather treatment is recommended for all persons living with HIV.

So in sum, HIV treatment is well tolerated (even if you have drug resistance), earlier initiation is thought to decrease risk of death and complications, and prevents transmission to others.

Some of the main reasons are (1) evidence that starting treatment with CD4 counts greater than 500 reduces risk of death and (2) decreased (not, as your doctors say) risk of developing drug resistance; (3) dramatically improved risk of side effects and toxicity of today's medications; (4) clear evidence that untreated HIV results in a highly inflammatory state and increased risk of cardiovascular, kidney and bone disease.

Some have argued that there "could" be risks of long-term toxicity of medication, but no studies actually show this- large studies, including EUROSIDA actually demonstrate the opposite. People who start treatment earlier and stay on treatment longer tend to have fewer side effects and toxicity.

If you have frequent night sweats, I would not classify you as having asymptomatic HIV disease, and rather, as having symptomatic disease that probably warrants treatment (even if one sticks to the 500 CD4 threshold).

I hope that's helpful. Please feel free to write back anytime. BY



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