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hiv , no meds and babies (WHEN TO START THERAPY)
May 30, 2009

i was diagnosed with hiv a few weeks ago and my viral load is around 10 000ish and my cd4 count is 500-600 (i had tonsilitis at the time of blood test) and my doctor has said that its not neccesary for me to take the meds yet untill my cd4 cell count drops unless however i can choose to start them now. im confused becuase most of the information i can find tells me that the earlier you start meds the better your chances at living longer. its all new to me and i researched my ass off so much so that my doctor didnt have enough time to answer all my tech questions! so if you could fill me in...

the reason that i found out i was hiv +ive was due to being pregnant but i lost the baby due to stress from the results and my partner and i want to try again as we are aware that there is less than 2% chance of the baby being hiv +ive and my doctor is unsure whether if i should start meds before we try to get pregnant again or whether to wait until after the first crucial three month period of pregnancy.

thirdly if my partner has hiv, which is highly likely if i have it, are we still able to procreate the regular way? hanky panky or sperm washing and ivf etc etc. can a hiv + sperm lead to +ive babies. becuase im guessing they are all out of our price range and we really want a bub

thankyou for your time dr

Response from Dr. Frascino

Hello,

I'm sorry to learn of your recent HIV diagnosis and miscarriage. The questions you raise are complex and are best handled via a conversation with your HIV specialist. I encourage you to discuss your questions and concerns with your HIV physician, as the information I can provide via this format cannot substitute for an in-depth face-to-face discussion.

As for the optimal time to begin combination antiretroviral medication, the truth is we don't know. The current guidelines recommend starting when CD4 counts drop into the 350 range. You are correct: More recent evidence suggests that starting earlier may be beneficial (decreased immune activation, preserved immune function, etc.). However, these potential benefits must always be weighed against the potential of drug side effects and toxicities. Personally I would encourage early intervention with antiretroviral therapy if the HIVer is ready, willing and motivated to begin. I'll reprint below some information from the archives that addresses this topic.

As for whether to take antiretroviral medications during the first trimester (first three months) of pregnancy, this depends on what your CD4 count and viral load are at the time of conception. If you have a reasonably low HIV plasma viral load and preserved CD4 count, I would support waiting until the second trimester after the period of organogenesis (period when the baby's organs are being formed). However, if your CD4 count was low and viral load sky high, I'd start treatment without delay. There is additional information in the archives of this forum in the chapter devoted to pregnancy. Check it out!

Regarding starting a family when one or both partners are HIV infected, yes it is possible. If the guy is "positively charged" (so to speak), sperm washing and IVF would be safest to avoid infecting a negative partner (or decreasing the risk of superinfection/dual infection in a positive partner). Hanky-panky is a bit riskier but there are some harm-reduction strategies that can be employed, including using antiretroviral drugs to drive the viral loads to undetectable levels. This would significantly decrease the risk of viral transmission. Also you should time your unprotected nookies to the period in your menstrual cycle when you are most likely to conceive. Before going into additional detail, I recommend you first determine if your partner is HIV positive or not. That should be your next step, along with an in-depth discussion of these topics with your HIV specialist.

Good luck.

Dr. Bob

Early Initiation of Antiretroviral Therapy Improves HIV Survival Rates, Study Says

April 30, 2009

The New York Times on Thursday examined a study that found asymptomatic HIV-positive people who delayed antiretroviral treatment until their disease reached an advanced stage faced higher mortality rates than those who initiated treatment earlier. According to the Times, current national guidelines recommend starting HIV-positive people on antiretroviral treatment when CD4+ T cell counts fall below 350; however, the recent study suggests that initiating treatment earlier could reduce the risk of death. The study, as well as a related editorial, appeared online in the New England Journal of Medicine earlier this month and both will appear in the April 30 edition of the journal. In addition, a separate study published online earlier this month in the journal Lancet developed similar conclusions about the benefits of earlier antiretroviral therapy initiation, the Times reports.

For the NEJM study, researchers led by Mari Kitahata, director of clinical epidemiology at the Center for AIDS and Sexually Transmitted Infections at the University of Washington, tracked survival rates for 17,517 asymptomatic HIV-positive people in the U.S. and Canada who received care from 1996 to 2005 and who had never previously taken antiretroviral therapy. For their first analysis, the researchers examined a group of 8,362 patients, 2,084 of whom started therapy when CD4+ counts were between 351 and 500. They also examined 6,278 participants with similar CD4+ counts who delayed therapy until their counts declined below 350. According to the study, the patients who delayed treatment had a 69% higher risk of death compared with those who initiated treatment earlier. For the researchers' second analysis, they examined 9,155 HIV-positive people with CD4+ counts of more than 500. Of those, 2,220 started therapy within six months, while 6,935 delayed therapy. Among those who postponed treatment, 3,881 experienced a decline in CD4+ levels and 539 started antiretroviral treatment within six months of having a CD4+ count of 500 or less. In addition, the researchers found that those who deferred therapy had a 94% greater mortality risk than those who initiated treatment earlier.

According to Kitahata, the study examined "one of the most important questions in the last decade: what the optimal timing is for starting therapy." She added that the recent research "provides evidence that patients would live longer if antiretroviral treatment was begun when their CD4+ count was above 500." According to the Times, the study is "not the final word on the matter" (Rabin, New York Times, 4/30).

Delaying HAART Might Prevent Complete Immune System Recuperation, Study Says

April 9, 2009

People living with HIV who do not start highly active antiretroviral treatment until their CD4+ T cell counts drop below 200 might not be able to reach a normal CD4 cell count, even after 10 years of otherwise effective treatment, according to a study in the March 15 issue of Clinical Infectious Diseases, Reuters reports. According to Reuters, an HIV-positive person is considered to have a normalized immune status after CD4 counts are maintained above 500.

For the study, researchers examined 366 HIV-positive people who had maintained plasma HIV RNA levels of no more than 1,000 copies per milliliter of blood for at least four years after starting therapy. About 25% of the study's participants were followed for more than 10 years, with a median follow-up of 7.5 years. Reuters reports that 95% of the participants who started therapy with a CD4 cell count of at least 300 were able to reach a normalized CD4 cell count of at least 500. The researchers reported that 44% of participants who began treatment with a CD4 cell count of less than 100 -- as well as 25% who began treatment with a CD4 cell count of between 100 and 200 -- were not able to reach a CD4 cell count higher than 500.

Lead author Steven Deeks of the University of California-San Francisco and colleagues wrote that a "persistently low CD4 cell count during treatment is associated with increased risk of both AIDS and non-AIDS related events," such as liver disease, cardiovascular disease and cancer. They added that "novel immune-based therapeutic approaches may be necessary to restore immunocompetence in these individuals." In a related editorial, Boris Julg and Bruce Walker, both of Massachusetts General Hospital, wrote that major treatment guidelines recommend beginning antiretroviral therapy when CD4 cell counts drop below 350, adding that it can be difficult for developing and low-income countries to follow such advice. Julg and Walker wrote that "adequate early therapy, leading to more-complete immune reconstitution, may save resources because of the resulting lower incidence of opportunistic infections and reduced need for medical care" (Reuters, 4/7).

Study Supports Earlier Antiretroviral Treatment, Researchers Call for Amended Recommendations

April 9, 2009

In in the journal Lancet on Thursday, researchers published findings that they say support calls for starting antiretroviral treatment earlier than some current recommendations, AFP/Yahoo! News reports. According to AFP/Yahoo! News, there are no universal guidelines for when HIV-positive people should begin highly active antiretroviral therapy, but a common recommendation is to begin the treatment when CD4+ T cell counts decline below 200 to 250. Some researchers argue that this recommendation is too low and that more lives could be saved if the treatment was started sooner, according to AFP/Yahoo! News.

For the study, Jonathan Sterne of the University of Bristol and colleagues compared previous studies that followed more than 45,000 HIV-positive people in Europe and North America (AFP/Yahoo! News, 4/8). The data for the study included 21,247 HIV-positive people followed from 1989 to 1995 -- before antiretroviral treatments were developed -- and 24,444 HIV-positive people since 1998, according to Reuters. All of the participants had not progressed to AIDS and had CD4 cell counts of less than 550. In addition, none of the participants reported a history of injection drug use (Reuters, 4/8). According to the study, people who began antiretroviral treatment when their CD4 counts were less than 350 were 28% more likely to develop AIDS or die prematurely than those who began treatment with CD4 counts of 351 to 450. The study also said that the findings support earlier HIV treatment initiation, particularly as new antiretrovirals have fewer side effects than earlier treatments. The study said, "In view of diminished concerns about toxic effects and resistance, our results suggest that 350 cells per microliter should be the minimum threshold at which antiretroviral therapy is started" (AFP/Yahoo! News, 4/8). According to the researchers, the beneficial effects of earlier treatment initiation were especially significant during the first two years of treatment.

The researchers also conducted a repeat analysis among 4,605 HIV-positive injection drug users, which showed similar results. The authors said the results "should be applicable to many patients starting or considering starting combination therapy in developed countries." In a related commentary also published in Lancet, Robin Wood and Stephen Lawn -- both of the University of Cape Town in South Africa -- said that the "question of when to start [antiretroviral treatment] might have more than one right answer." Wood and Lawn noted that the risk-to-benefit ratio of early antiretroviral treatment initiation remains uncertain in developed countries, adding that in low-income settings, the prevalence of AIDS and AIDS-related deaths are typically higher both before and after starting treatment. In the commentary, the authors suggested randomized trials that take into consideration such issues in both types of settings (Reuters, 4/8).

Earlier Antiretroviral Treatment Could Reduce Risk of Death in HIV-Positive People, Study Finds

April 2, 2009

A study published Wednesday in the New England Journal of Medicine suggests that starting HIV-positive people on antiretroviral treatment earlier than what current guidelines recommend could reduce the risk of death, the Wall Street Journal's "Health Blog" reports (Goldstein, "Health Blog," Wall Street Journal, 4/1). Researchers in two separate analyses examined the medical records of about 17,000 HIV-positive people (Waters, Bloomberg, 4/1). They looked at participants' CD4+ T cell count, starting with 8,000 participants in the first analysis. The researchers compared patients who began antiretroviral treatment within six months of receiving a CD4 count between 351 and 500 with those who delayed starting treatment until after their CD4 count was 350 or less. The patients that delayed treatment had a 69% higher risk of death during the follow-up period.

For the second analysis, the researchers studied 9,000 patients, comparing those who began treatment six months within receiving a CD4 count of 500 or greater with those who delayed starting treatment until their CD4 count was below 500. The researchers found that there was a 94% higher risk of death among patients who delayed treatment ("Health Blog," Wall Street Journal, 4/1). Bloomberg reports that the study adds to growing support for changing current guidelines, which recommend starting HIV-positive people on antiretroviral treatment when CD4 counts fall below 350. Current guidelines also say that doctors can decide on an individual basis whether patients with CD4 counts above 350 should begin treatment. For several years, doctors and patients have struggled with when to begin antiretroviral treatment, which can have significant side effects such as nausea, stomach issues, changes in blood fat levels and altered mental processes, Bloomberg reports.

Reaction The study adds "weight to a growing body of research that suggests treating HIV at earlier stages can help save lives," Bloomberg reports. "The drugs are now safer and the evidence mounting from our data and other data suggests it makes sense to start therapy earlier," Richard Moore, study author and professor of medicine at Johns Hopkins Bloomberg School of Public Health, said. Jason Kantor -- an analyst with RBC Capital Markets in San Francisco -- said the study's findings are already known to many doctors but that they still are likely to spark increased use of antiretroviral treatment. Brad Hare, medical director of the University of California-San Francisco's Positive Health Program at San Francisco General Hospital, said the study provides "a scientific foundation for a practice that a lot of patients and doctors have already been doing, namely starting medications earlier."

Harvard Medical School researchers Paul Sax and Lindsey Baden write in an accompanying editorial that the findings cannot be considered conclusive because researchers did not randomly assign patients to begin treatment at different stages but analyzed patient records, Bloomberg reports. The editorial says, "The supportive evidence for the benefits of earlier therapy continues to increase," although the study did not "provide definitive proof that we should start antiretroviral therapy in all" HIV-positive patients (Bloomberg, 4/1). Sax and Baden also write that the participants who began treatment earlier might have differed from those who waited in ways that improved survival rates and were independent of when they initiated therapy. To address this, researchers should randomly assign patients to begin therapy earlier or later and determine which group fares better, the editorial says, noting that at least three such studies are ongoing or planned ("Health Blog," Wall Street Journal, 4/1). Hare said that the study will spark a discussion into changing current guidelines on when to begin treatment and whether the government should fund a randomized clinical trial. The study was sponsored by two federal agencies, including NIH (Bloomberg, 4/1).



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