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Starting treatment for better relationships
Jun 13, 2011

Dear Dr, I am an HIV+ person and I need your advise in whether or not to start treatment. My last labs showed a CD4 of 431 and viral load 22,590. I have been monitoring my condition for two years and I have never gotten to the point where treatment is necessary. I do have some upsets like joint pain, continuous throat problems, etc, but other than that I am active, do exercise and have never found necessary to stay home because of sickness or anything. Two things are making me consider starting treatment: 1) improve my quality of life, and 2) have better relationships. I read recent an study in the New York Times (May 12, 2011) that claims that people under treatment, with undetectable viral load has almost no possibilities of transmitting the virus. The is a related paper from Swiss experts that goes even farther and claims that people with no other STDs, under treatment, and with at least 6 months of continuous undetectable viral load can not transmit the virus and can have children by natural ways and have unprotected sex (Vernazza P et al. Les personnes séropositives ne souffrant daucune autre MST et suivant un traitment antirétroviral efficace ne transmettent pas le VIH par voie sexuelle. Bulletin des médecins suisses 89 (5), 2008; English like at http://www.aidsmap.com/Swiss-experts-say-individuals-with-undetectable-viral-load-and-no-STI-cannot-transmit-HIV-during-sex/page/1429357/ ) I would like to know first what is my probability of transmitting the virus with my current numbers, what should I say to potential partners when disclosing my status in that regards?, and second how that probability would change if I start treatment, the pros and cons.

Response from Dr. Frascino

Hi.

We cannot provide a "probability of transmitting" HIV based solely on viral load and CD4 counts. What we do know is that anyone who is HIV infected is considered to be infectious (capable of transmitting the virus to others). We also know that those with higher HIV plasma viral loads are more likely to transmit the virus. Recent studies have provided additional scientific evidence that the use of effective combination antiretroviral therapy significantly decreases the risk of HIV transmission. However, it is incorrect and potentially dangerous to interpret these reports as an indication that there is no risk. I have discussed the Swiss report many times in this forum. Check the archives for that discussion.

As for what you should say to potential partners, you should disclose your HIV status as positive. You should not suggest you are not infectious, even if you decide to go on treatment and your HIV viral load is driven to undetectable levels.

Finally, regarding when to begin treatment, the most recent guidelines revision recommends antiretroviral therapy be started when the CD4 count falls to 500. Many of us strongly recommend beginning treatment as soon as the diagnosis is made, even if the CD4 count is well above 500, to prevent damaging immune activation and to preserve immune function. As noted above, we now also have strong scientific evidence that being on treatment significantly decreases (but does not totally eliminate) HIV-transmission risk.

Dr. Bob



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