Dear Doctor Sherer I am a constant reader of your site, I am 61 YOA. I live in Thailand and my doctor here is still under the impression that I should not start on medication until my CD4 count goes down to 250, this is after I showed him a print out of your recommendations to start meds above 350 which is now recommended by the U.S the UK and Europe. He stated that they have not been informed of these new figures by the Thai medical board to date.

I am a bit worried as I was diagnosed to be HIV Pos in August 2006, CD4 = 553, V/L = 200,000. Feb 2007, CD4 = 479, V/L = 264,000. Sept 2007, CD4 = 695, V/L = 500,000, Percentage 23%. Jan 2008, CD4 = 523, V/L = 170,000, Percentage 31%

I dont understand too much about the illness and am confused whether I should be on meds for the high V/L, or whether I should be on meds for CD4?

If I should be on either meds, what would you recommend, or what would you recommend I do. Worried.

Between the CD4 and the viral load, the CD4 is the stronger predictor of disease progression. Your case is somewhat reassuring because you have maintained a consistent CD4 cell count in spite of your viral load.

There is intense discussion now at WHO and among national health leaaders in emerging economies and the developing world on the question of whether the indication for ART should be expanded to include earlier HIV disease, as our guidelines in the US and Europe now recommend. These questions have complex issues at stake, including the enormous extra cost of starting earlier compared to the less pronounced benefits in a given population. However, for the individual with HIV, there is consensus in the US and Europe that starting ART when the CD4 cell count is around 350 cells leads to the best outcomes for the individual.

Having said all of that, your current values and your trends are reassuring, and I might well suggest that we defer treatment and observe your viral load and CD4 further at this point, rather than starting you on ART, if you were a patient in my practice in Chicago. I would certainly follow you closely and monitor your values every 3 months to ensure that any negative trends are identified promptly.

I suggest that you talk to your doctor about your concerns and these responses. There are also several clinical trial units in Thailand (such as the HIV-NAT Network) that may have an opportunity for you to receive treatment outside of the Thai national guidelines, and you and your doctor may want to look into that.