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start meds
Oct 10, 2007

I received my numbers today from my dr. MY cd-4 couint is 323 my viral load is 361, should I start meds?

Response from Dr. Sherer

What did your doctor say? I will offer some observations based on the information you have provided, but your doctor has additional information that I lack that would help me to make a specific recommendation to you, so I suggest that you return to him or her with your question and this response, and talk some more about it.

The current guideline recommendation has two clear thresholds for when to start ART, and when NOT to start ART, and a fairly large grey area when treatment may or may not be started. You fall into the third category. You and your doctor can reasonably choose to start now, or to wait a short period while you observe your CD4 cell count and viral load trends.

It is widely accepted that all people with AIDS, with serious HIV symptoms, and/or with CD4 cells below 200 should be started on ART as soon as possible.

It is also widely accepted that people with CD4 cells above 350 cells/ml do not require immediate treatment. People in this category should be followed closely with regular CD4 cell counts and viral loads to determine the trends in the CD4 cell counts and viral loads over time.

And finally, when a person has no symptoms of HIV and a CD4 cell count is between 200 and 350 cells/ml, it is recommended that treatment be CONSIDERED. Other factors that could play a major role in whether or not to treat, as well as what regimen to use, are co-morbidities such as hepatitis B or TB, whether the patient is a pregnant woman, the readiness of the patient to commit to long term ART and optimal medication adherence, other medical conditions and medications that might have an impact on HIV disease progression or interact with ART, and more.

Recently, there is additional evidence that an earlier start of ART, e.g. when the CD4 cells are at 350 cells/ml or below, provides benefit. Adverse drug reactions to ART, for example, appear to be lower when treatment is started around 350 cells/ml, as compared to a start at 200 cells/ml. Although there has never been a clinical trial to test the optimal time to start therapy, the SMART study showed that immediate ART in over 200 patients with CD4 cells around 300 was superior to delayed ART in a different group of 200 patients(i.e. no ART treatment was given until this group reached a CD4 cell count below 250 cells/ml) in BOTH the HIV-related opportunistic infections AND in non-HIV causes of morbidity such as heart disease, kidney disease, and liver disease.

My own advice to my patients, then, is that ART be started when the CD4 cell count falls below 350 cells/ml. So my response to your question is yes, I would be inclined to advise you to start ART...but my final recommendation would require the answer to all of the questions that I noted for patients with CD4 cells between 200 and 350 above.

Two other points: First, current guidelines suggest that a very high viral load above 100,000 copies/ml should also be a factor in whether or not to start ART. This is not a concern for you at present.

Secondly, a genotype resistance test is recommended in any patient prior to starting therapy. Although it may be difficult to get a resistance test with a viral load below 1,000 copies/ml, in some cases you can sequence the virus at lower levels, so you and your doctor can repeat the viral load and request a resistance test, even with a viral load in the hundreds.

Again, talk to your doctor about your question and these responses.


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