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When to start medication
Aug 27, 2007

My wife and I recently went for an HIV test and we both tested positive. My viral load is 570,000 and CD4 count is 650 and my wife's viral load is 37,000 and CD4 count of 500. We dont quite understand what these results imply to us. I have a very hgh CD4 count and a very high viral load and my wife has a low CD4 count and low viral load. Is it advisable to start treatment now and what drugs are likely to be recommended for our treatment?

Response from Dr. Sherer

The current HHS Guidelines suggest that ART should be considered in people who have no symptoms when the CD4 cell count is below 350 or the viral load is above 100,000. Both of these tests are useful predictors of the likelihood of HIV disease progression.

My own opinion, based on these data, is that you should probably be on treatment now, and your wife can wait.

Because your CD4 cell count is high, however, you also have the option of waiting 1-2 months and repeating these tests to observe the trends in both the CD4 cell count and the viral load. If you were recently infected, for example, it is possible that you had not yet arrived at the viral load 'set point' which is usually quite stable, and which can predict the likelihood of disease progression. If that were the case, your next viral load value might be lower, e.g. below 100,000, and your indication for treatment might be less strong.

I would only suggest a brief period of observation, however, if you chose to go that route.

You and your wife should talk to your doctor together about these issues. I appreciate that it might be easier for you both to act together, i.e. to both be on ART, or to both wait, and that is a factor for your doctor to take into consideration.

To understand the relative significance of these two tests, we often use the analogy of a train headed towards a cliff where the bridge is out. The CD4 cell count is like the distance to the cliff - the greater the number, the longer the time before disaster. The viral load is like the speed of the train. The viral load is the rate of disease progression, and in that analogy your train is moving at a fast pace.

As above, I urge you to talk to your doctor about these concerns. There are other issues that bear on starting treatment as well, like the result of your genotype resistance test, other possible co-morbidities like hepatitis or TB, the presence or absence of HIV-related symptoms, other medications that you take (if any), other medical conditions (if any)....and only you and your doctor can reasonably address all of these issues, and not a single question/answer interaction on the internet.


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