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Time for treatment?
Nov 2, 2008

Dear Dr Bob

Firstly, a huge thank you to you and your colleagues for the info and support you provide on this site - you have been a real comfort to me over the last few years since I learnt that I am hiv+

I am having a bit of a dilemma regarding treatment. My latest lab results are CD4 354, VL 69000, 23%. My cd4 count has been hovering around the 350 mark for the last 6 months are so. My doc has suggested that I wait for another 3 months as my percentage is ok and I am asymptomatic. In some ways I am happy to do this, but I am concerned that the growing trend seems to be to start meds earlier rather than later. What's your take on this?

My clinic is also about to start a clinical trial using the new drug TMC-278. My Doc has asked me to consider joining the trial when I do start meds. Again, I'd appreciate your opinion on this drug as a first line treatment (I think it will be in combination with another drug).

Sending you buckets full of good karma!

Irish Dave

p.s. If your fellow citizens do not vote for Obama, it will be a crying shame!

Response from Dr. Frascino

Hello Irish Dave,

Waiting an additional three months most likely won't change things significantly. You can plot out your CD4 count and viral load results on a graph and look at the long-term trend over time. That said, personally, I would recommend beginning therapy now if indeed your CD4 counts have been hovering around the 350 mark for six months. I'm one of the HIV specialists advocating for earlier treatment based on recent data related to survival and our improved knowledge of HIV pathogenesis. (See below.)

As far as TMC-278 or any experimental therapy, there are many unknowns related to any clinical trial. There are potential benefits as well as potential risks. You'll need to weigh these carefully. In addition, there is the benefit to the "greater good" by volunteering for clinical research trials. I'm not sure which TMC-278 trial you are considering. I would assume it's the one comparing TMC-278 to Sustiva. The study will compare potency, efficacy, tolerability and safety. The early data on TMC-278, a new non-nucleoside reverse transcriptase inhibitor, looks promising, but obviously our knowledge is incomplete, as experience with this agent is limited.

Good luck, whatever you decide.

Dr. Bob

early treatment?plz help(2) Nov 2, 2008

Hi Dr Frascino, I am the guy who asked you why you suggest to consider early treatment during seroconvertion. Thanks for your answer and the advice:I really appreciate it. About me undergoing treatment, my hiv-specialist says the choise is mine but he adviced me not to undergo treatment becuase the CDC guidelines speak very crearly:they say 200-350 (or a very high viral load);he pointed out my cd4 has been stable at 830 since seroconvertion(i will add details of my exams and my story later in this message if you have time and you are willing to read) he added he doesn t know he cannot predict when i will need medicines but anyway 3 4 5 8years for sure the treatments options will improved so it s worth waiting. He added that taking medicine because i am part of a magnetic couple is not what he thinks a good reason because the love story can end one day,nothing is for ever he said. still if i decide to undergo treatment he will make the prescription of course. what i really think is that if the guidelines say 350 there should be a reason and maybe is better to stack with what they say.

my bf and I, never though about unprotect sex and lowering my viral load is not a way to relax to unsafe sex:it s just to put the both of us in a "safer" enviroment:even if we engaged in one of the statistically safer activity(hiv speaking) condom failures do occur sometimes(I learnt this the had way,I seroconverted because of that although we stopped immediately-i didnt took PEP,for various reasons that i dont want to remember)so an udetectable viral load will make us feel better i guess. I read about the swiss statement and even if eventually i will be undetectble for six months-already i dont have other STD)we will keep going with safe sex. My doubt is that i read somewhere but I cannot tell you where,that the viral load detected on the blood is not necessarily related to how abundant is the virus in the anal mucus,while I think I read the plasma vl is correlated to that one present in semen and other fluids... so will it really be less risky for my partner if my viral load would be undetectable?

my story in brief: i felt safe after the accident because we stopped immediately and because he was more worried than me,he wanted to be assured i was neg etc.this happen in middle november. after a episode of fever and diaherreia in middle december I did blood test and i got test for hiv:two elisa with diff metodologies resulted positive.They perform a wb indeterminate with gp160 p24 and p53 present. i went to my actual specialist he expressed his opinion that i was seroconverting(given the bands reacting on the wb also he cannot ignore two pos elisa) but that he cannot say that "officialy".he ordered a vl test then with counting of cd4 cd8. at the end of january i did those test vl 5300 cd4 730 28% the doctor declared i am hiv positive because virus was found in my blood. end of june cd4 809 31% no viral load performed end of october vl 7000(pcr) cd4 830 32% (i forgot to tell you i met my bf in february, i disclosed very soon to him) with this numbers do you really advice early treatment(I repeat my self, I just would like to listen another opinion) can you provide me a link for that conference you citated at the beginning of your answer(that one in washinton?) by the way, how can i donate? sorry for my bad english, i m Brazilian and thanks personally for answering my previous question and a more general THANKS for all the job you are doing here: you are really helping a lot of people.

Response from Dr. Frascino

Hello Brazilian Guy,

Your situation is quite different from someone in the midst of HIV seroconversion. You have been followed for the past 10 months and appear to have very low HIV plasma viral load levels and high CD4/CD4%. Your seroconversion occurred quite some time ago. Your choice now is when to begin antiretroviral therapy. As I mentioned previously, the current trend is to begin treating earlier due to several confluent factors. First, we have learned much more about HIV pathogenesis, immune activation and immune restoration. Second, we now have many more antiretroviral therapies available in our treatment armamentarium. Some of these new therapies have novel mechanisms of action and many are better tolerated with fewer side effects and more convenient dosing regimens. That is why many HIV treatment guidelines have moved the start-treatment count up into the 350 range. These new guidelines were released earlier this year and are still making their way into clinical practice. More recently still (in fact just this week), new information was presented at the infectious diseases meetings in Washington that suggested HIVers should consider starting treatment even earlier than at a CD4 count of 350. A large clinical study looked at HIVers who started therapy at CD4 counts between 350 and 500 and compared them to those who waited until the CD4 count dropped to 350. The researchers found a 70% improvement in survival for the early starters! These data are very compelling and fit well with our evolving knowledge of HIV pathogenesis. There has been widespread belief that the potential side effects of antiretroviral drugs, such as heart problems, increased cholesterol, diarrhea, nausea, etc., were perhaps worse than having HIV. And so, if HIVers waited as long as possible to begin treatment, they could have fewer side effects to contend with. That view is changing in light of the newer, better tolerated HIV drugs and the new survival information. Additional studies are underway to see if these initial findings can be confirmed.

Your second point has to do with the harm-reduction strategy of driving your HIV viral load down to undetectable levels to significantly decrease the risk of HIV transmission. This is a personal decision that only you can make with the input of your negative partner and HIV specialist. I should also point out there are other harm-reduction strategies to consider as well, including PrEP (Pre-Exposure Prophylaxis). This would involve the HIV-negative partner in a magnetic couple taking antiretrovirals as prophylaxis. Clinical trials of PrEP are underway. And even though we don't yet know how effective this approach will be, some magnetic couples aren't waiting for the results of the trials. They are starting PrEP now.

These issues of when to start treatment and harm-reduction strategies for magnetic couples using antiretroviral drugs are completely unrelated to the issues of using antiretroviral therapy during primary HIV infection and/or HIV seroconversion. There is some information using antiretrovirals at this very, very early state of HIV infection may be helpful in preserving immune function and decreasing immune activation. These are very complicated issues and we don't have firm recommendations yet. However, I feel it's important for HIVers to have the latest information so that they can be active participants in their health care decisions. My personal feeling is that we will continue to move in the direction of earlier and earlier treatment. For now, the motto for HIV treatment remains: "One size fits one!" What's right for someone else may not be right for you.

Donation information for the Robert James Frascino AIDS Foundation can be found on the foundation's Web site, www.concertedeffort.org. Just click on the "Donate" tab.

Good luck. Be well. I'm here if you need me. Let's get through this together, OK?

Dr. Bob



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