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Do I Start Meds - Possibly New Infection
Jul 25, 2008

I had been testing regularly, and my last -ve test was in 2005. In November 2007 I tested +ve. As I had practised safer sex until some lapses in 2007, i suspect it is a recent infection. My CD4 was around 200 in 2007 with VL of 113,000. I have been monitoring this MONTHLY with my HIV Dr and my CD4 is still hovering around 200 with VLs that fluctuate between 3,000 to going back up to 65,000. I have no symptoms & am otherwise healthy. I am prepared to go on meds, but I wld like to spare my body the toxicity if there is a chance that my CD4 will improve, & VL will stabilize at some point. I read for new infections there could be fluctuations for up to 12 months from infection. I am not in denial, & have in fact got the meds in front of me - if i need to i'm prepared. Appreciate some insights into how HIV works for new infections. Thanks so much!

Response from Dr. Sherer

All of the current guidelines in the US and elsewhere in the world agree that you should start ART now. You and your doctor have lost nothing, in my opinion, by taking this decision quite slowly and deliberately, but I think the clinical data are now solid and convincing that it is in your best interest to start ART now, before you develop an AIDS-defining opportunistic infection, or become ill in some other way, due to HIV infection.

The viral and CD4 set points tend to stablize after 6 months, as you suggest. You first tested positive in 11/07, suggesting that infection occurred sometime between your last test in 2005 and a few months before this last test. Hence more than 6 months are likely to have elapsed since infection; furthermore, you and your doctor wisely chose to look at the trends in your CD4 cell count and viral load since 11/07, and they did not vary substantially during that time.

Note that for one viral load to differ significantly from another, a 0.5 log or 3x change is required; otherwise, the background 'noise' or natural variation in the test itself may be responsible for smaller changes. Hence your first viral load of 113,000 is not clinically different than a viral load of 65,0000, which is less than 3x lower.

For a 35 yeaer old with a CD4 cell count of 200 and a viral load of 30,000 (on average), your 6 month probability of developing clinical AIDS is 4%, but that number jumps to 9.3% if the CD4 cell count falls to 100, and rises to 13.2% if the CD4 cell count falls to 100 and the viral load exceeds 100,000 copies/ml. (These data are taken from table 4b on pg 61 of the Jan 2008 US HHS Guidelines, the link for which is noted below.)

Most guideline panels recommend treatment before a clinical illness occurs, and the CD4 cell count of 200 is the most common threshold, below which OIs and other forms of illness begin to occur. I strongly advise you and your doctor to take the next step and start treatment. I would also suggest that you take TMP-SMX or another agent to prevent pneumocystis pneumonia as well, until such time as your viral load is below detection for >3 months and your CD4 cell count is high enough for your doctor to recommend that you no longer need to take it.

Finally, you and your doctor will need to review the other key information in your assessment before starting ART, including the results of your resistance test, your baseline labs, medication adherence, other medical conditions and/or medications (if any), and other issues.

I suggest that you talk to your doctor about your question and this response. HHS ART Guidelines

Viral Load increasing
So which is it?

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