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which drug is the best
May 8, 2004

my viral load is 115,000 and my t-cell is 375. should i start treatment or should i wait

Response from Dr. Sherer

According to the US HHS Guidelines for the use of antiretroviral therapy (ART), you are in a 'grey zone', in which you and your doctor could reasonably decide to start ART now, or to await the next set of lab values and postpone thereapy. (Note the link to the guidelines below)

My own personal recommendation would be to start therapy, IF you are ready to do so, and willing to completely adhere to the regimen.

The HHS Guidelines suggests that therapy be begun when the CD4 cell count is 350 cells or below, or if the viral load is 55,000 copies/ml or above. In both cases, the guidelines acknowledge that there is no absolute answer, and much depends on how you and your doctor interpret the available clinical evidence, and how willing you are to accept the discipline needed for successful ART.

The clearest CD4 cell level below which morbidity and mortality from HIV disease increases substantially is 200 cells/ml. However, several cohort studies have shown that mortality and morbidity begin to increase at levels below 350 cells. This might lead physicians to treat everyone at that level...but other factors also influence the chance of successful ART, including adherence, side effects, other conditions like hepatitis C, and other factors. So you are near to 350 CD4 cells now. Personally, I agree with the guideline recommendation to consider ART once the CD4 cell count is at or below 350 cells/ml, in part because time may be needed to establish all that is needed for successful ART. For individuals with CD4 cells of 200 or below, there is no margin for error, and no time to work on optimal ART.

In your case, the viral load is important. There is evidence in several ART cohort studies that a baseline viral load over 100,000 is associated with a greater chance of an AIDS opportunistic infection, as well as a more rapid clinical progression to AIDS, i.e. more rapid CD4 decline. That is why I would suggest that treatment is indicated now.

Still, you should not take this response as the last word. You should talk at length to your doctor about these issues, and let your doctor know how you feel about ART, whether its based on anecdotes, your own reading, or other sources.

If you and your doctor DO choose to start ART, additional time should be spent on the options for therapy, dosing, side effects, etc., and your doctor may want to obtain a genotype to look for resistance mutations in the virus that you acquired.

As there in no emergency to starting ART in your case, you and your doctor could choose to confirm the results you shared with me with a second set of tests, and a genotype, to confirm these results, and gather information about resistance that will be important when you do start your regimen. The 2-4 week delay would not do serious harm, and it would provide a clearer basis of making these decisions.


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