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Looking for consensus
Oct 2, 2014

Dear Doctor Young. My partner has been recently diagnosed HIV+, with a VL of 1500 copies/mL and CD4 1150 cells/mm3. He's only 19 and his Doctor has recommended him not to start treatment yet (although he has offered it to him if he wants to start now). The doctor thinks that, bearing in mind his current health status, it would possibly be more negative rather than positive to start treatment now because of the medication toxic effects (although nowadays toxicity and side effects are much less important than were before. Still are important though). I've been reading about when to start treatment and I have to say its beyond me the differences that I've found out between the US guidelines (and some other countries like Brazil) and the recommendations by the WHO. On one hand, US guidelines recommend to start treatment for any VIH+ person (very very specific cases apart), no longer taking into account CD4 counts or VL as isolated indicators. Some of the reasons include there are some evidences indicating an early treatment could have benefits in terms of better body tolerance, less viral resistance and a decrease in the risk of other health HIV-linked issues (inflammation, etc.). On the other hand, there is the WHO, which recommends starting treatment after the CD4 count is below 500 and/or high VL (other risk factors such as malnutrition in undeveloped countries and special situations apart), or in some conservative countries even below 350. Yet, no studies can fairly demonstrate the long-term toxic effects of taking the medicines (further than theoretical models based in short-term responses) because of how recent the virus and its treatment is, and how rapidly new medicines become available in the market. So, I am not just looking for an answer to know whether to start treatment or not immediately (of course I would appreciate your opinion about it keeping in mind my partners record), but I am trying to build up a discussion. So, I am a PhD in Chemistry, I understand that every case is an isolated case, every single individual is particular, and medicine is an experimental science. I can also accept that opinions between experts may differ; it is such a complex topic. Also, besides politics, capitalism, economics and personal interests, I am trying to find solid arguments to clarify how such an important decision of when to start treatment has to be made. Also, how world leader organizations/institutions have not reached a consensus around it yet. This virus, which can eventually lead to AIDS, has killed millions of people. And is killing millions of people. And will kill millions of people. I have hundreds of questions from a scientific point of view, and I dont want to bother you about them so that would be my comments for now. By the way, at the moment, I am HIV-.

Thank you for your time,

Response from Dr. Young

Hello and thanks for posting your thoughtful questions.

I think that there already is consensus.

One should recognize that the World Health Organization (WHO) guidelines, as important as they are, are lagging, not leading indicators of the science. This is because guidelines sometimes reflect political and economic considerations, and the WHO has to be mindful of all countries considerations in a single document.

US guidelines by contrast, tend to not take into consideration costs, but rather the best scientific opinion. Having said that, it's notable that in their recent treat-all recommendations, the Brazilian government noted that their recommendation was based both on scientific and economic considerations.

It's also important to note that, in my opinion, the focus on a CD4 count threshold for treatment start is somewhat myopic. Even the WHO guidelines say that in addition to those people with CD4s below 500, all pregnant women and mothers as well as sexually active people should receive treatment (this means that taken together, most are treated).

Toxicity and side effects, as you rightly point out, are very important and the tolerability and safety of today's medications are vastly better than those used only a few years ago. There are indeed fairly long-term (5-10 year) safety studies on our medications, including a massive 16,000 patient, 100 clinic study from EUROSIDA that showed no risk of increased death with longer treatment; another study suggests that early initiation of HIV treatment is associated with death rates and causes that resemble HIV-negative populations.

Your right, millions will die unnecessarily from HIV/AIDS- roughly 4000 each and every day. HIV medications are dramatically safer, dramatically easier to take and don't require the precision or perfection in adherence that they once did.

UNAIDS just announced their goals for global HIV programs over the next 5 years- 90% of positives will know their status, 90% will receive HIV medications (without regard to CD4) and 90% of treated persons will achieve undetectable viral loads. 90/90/90 has broad support from governments, researchers, doctors, patients and human rights advocates. 90/90/90 acknowledges that there are enormous challenges- particularly in dealing with stigma, discrimination, criminalization and reaching marginalized populations of people. Yet, achieving 90/90/90 will make epidemic death from AIDS and new infections rare.

There is growing global consensus on when to treat. Indeed, as my friend and colleague Joep Lange said just before his death on MH17, "the available evidence renders the discussion on when to start ART unnecessary and that, instead, efforts should be aimed at offering treatment as soon as possible." I think it's time that we all demand an end to preventable death from AIDS.


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