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Should I start treatment?
Dec 25, 2009

Hey Dr.Frascino, I cant believe its been almost 5 years the last time I asked u a question. I used to read your answers everyday religiously when i first got diagnosed. Then I guess accepted the fact and said it is what it is and there's no need to obsess over it. But I need your help now, again. The past 5 years my T-cells are between 550 highest and 329 lowest, last 2 bloodtests they were around 430. Viral load 30k highest and 5k lowest, lately around 7K. After 5 years my doctor thinks I should start treatment even though my numbers seem okay. She says we can only find out the number of t-cells but not the quality of them. And its better to prevent cancers and cardiac problems that may happen in the future. Im taking vitamins, eating well, not exercising but walking everyday. I sleep well. So I take care of myself and I feel healthy. The numbers go up and down but i honestly dont feel any difference.Im scared of nightmares and all the side effects i may experience with the meds. But I wanna stay healthy and I dont want the virus to harm my immune system. One other concern, its already hard to live with hiv and dating, and disclosure and all, it may sound shallow but I dont wanna look like I have aids. When will I show thw signs on my body, like fat loss on my face, if I start taking meds. I know Im all over the place but my maion question is "Should I start treatment or should I wait till my tcells drop 350 constantly, and not go higher?" Thank you so much in advance

Response from Dr. Frascino

Hi,

Welcome back to the forum!

To answer your main question about starting combination antiretroviral therapy, personally I would advise you start. (See the detailed response below for the rationale behind this recommendation.)

Regarding your fears of "nightmares," these are associated primarily with Sustiva. If this is a major concern, you could start a regimen that does not contain this drug.

Lipoatrophy (fat loss) is primarily associated with certain antiretroviral drugs: d4T (Zerit), AZT (Retrovir, Combivir, Trizivir) and ddI (Videx). Luckily, we now have excellent alternatives to these drugs. Please note we have an entire expert forum devoted to the topic of facial wasting. Check it out for the latest information.

Good luck! Happy Holidays.

Dr. Bob

To start meds or not to start meds, THAT is the question. Dec 25, 2009

Hi Doc,

I am recently diagnosed. My numbers have been very good my last two blood tests. CD4 of 955 and viral load of 125 (not thousand, just 125). I am debating whether to start my treatment or not. My doctor told me of a research study conducted on HIV+ individuals with CD4 levels between 350-500 and another group with CD4 levels 500+. In the 15-yr study the group with the CD4 levels 500+ had better overall health.

I received mixed opinions about whether to begin the meds now or not. My doc sited that study when I asked him what he would do. I am considering starting on Atripla and am aware of the side effects. Given my numbers and the fact that I am in overall excellent health for a man of 43, let me ask you now, what you YOU do if you were in my position?

Thanks,

C in OC

Response from Dr. Frascino

Hello C in OC,

I've been asked this very question a number of times. Personally, I would start combination antiretroviral therapy immediately to preserve immune function and decrease the amount of immune activation caused by HIV replication. Having said that, I must quickly admit to several caveats:

1. This is what I would do based on the scientific information we have to date. However, it is not a recommended guideline, nor do we have enough scientific data to claim it's the right thing to do in all cases!

2. The potential benefits of early intervention must be weighed against the risk of short- and long-term drug side effects and toxicities. In addition, there is the inconvenience of taking medication consistently on a daily basis as well as cost considerations that must be factored into the decision.

I'll reprint below some information from the archives that discusses when to start treatment. Please note the reason you received "mixed opinions about whether to begin the meds now or not" is there really isn't a right answer. Ongoing clinical trials will eventually answer the question definitively sometime in the future. For now, the best you can do is consider the various opinions and decide which feels right for you based on your particular situation. As you make your decision, you'll want to consider also your motivation to begin early intervention treatment. Once you start, it's best if you remain on treatment.

Good luck. Happy Holidays.

Dr. Bob

When to Start Treatment / What drug to Start On Aug 30, 2009

Dr. Bob,

I emailed you about a week ago re: negative antibodies but indeterminate PCR after oral sex. Sadly, I got the bad news last night. Viral load of 67,000. Antibody test indeterminate, but expecting that to be positive soon.

I had a very good meeting with my new case managager at Kaiser. The question for me is -- when to start treatment. My gut feeling is to start right away. If I can knock it back down, then let's go for it, I say. I wanted to know what you thought. Also, what drug would you take. Atripla seems to be the popular one right now ... one pill a day seems doable, the side effects seem manageable. I realize I'm going to have to start taking better care of myself overall (I'm in decent, not great shape). So my plan is -- start ASAP, Atripla, get in better shape, hope for the best. Please let me know what you think. Thank you and thank you for this site.

Response from Dr. Frascino

Hello,

Your next step is to meet with an HIV specialist physician. Your HIV status is still somewhat in question and needs to be confirmed one way or the other before you begin focusing on when to begin antiretroviral therapy! Whether you are poz or neg, I agree you should start taking better care of yourself!

If you are HIV infected and decide to begin treatment, I would recommend an HIV resistance test (genotype) before choosing a regimen. It is possible to acquire a strain of HIV that is already resistant to one or more antiretrovirals. If your virus is sensitive to all three components of Atripla, it would be a reasonable choice for first-line treatment. However, don't jump the gun! See the HIV specialist, get a firm diagnosis and confirmation of your status, check for resistance if you turn out to be positive and then discuss all treatment options with your doctor. I'll reprint below some information from the archives about when to start treatment.

Good luck. Write back and let us know what happens. Considering your HIV risk was "oral sex," it's quite possible your "PCR" is a false negative and your "indeterminate" antibody test will turn out to be negative. I believe this is still a strong possibility based on the information provided to date.

Good luck!

Dr. Bob

when to start (WHEN TO START TREATMENT, 2009) Jul 12, 2009

as of my last blood work i have a cd4 count of 326 and a viral load of 12,600 and a cd4 percentage of 25% i have been positive for 3 years and this is the first time the cd4 has dropped below 350 and at the time of the bloodwork i was positive for chlamydia, besides that i am very healthy. What should i do? Sincerely, Leery of starting therapy

Advertisement Response from Dr. Frascino

Hi Leery of Starting Therapy,

I would suggest you have a discussion with your HIV specialist to thoroughly discuss the pros and cons of beginning treatment. I would certainly encourage you to consider starting. However, not until the reasons for your leeriness have been completely cleared up.

I'll reprint below some information from the archives about when to consider starting treatment.

Good luck.

Dr. Bob

should i wait? (WHEN TO START TREATMENT, 2009) Jul 11, 2009

i was diagonised in aug 08. my last risk behaviour was eight months before diagnosis. this was unprotected oral and protected vaginal intercourse outside monogamous relationship. i had unprotected intercourse with my wife since the risk behaviour and until i was diagonised. she became pregnant but remained uninfected (and the baby too). my bloods say that my VL has remained high (>100 000). My CD4 count has been going up from 280 at diagnosis to 520 currently. The doctor says to hold off treatment for now. He also says I should be very careful as I am highly infectious. I dont understand why my partner could not get infected after eight months of unprotected sex. Is it normal for one partner not to pick the infection in such circumstances? Is there any benefit in delaying treatment?

Response from Dr. Frascino

Hello,

I'm sorry to hear about your recent diagnosis.

Regarding your wife, yes it is indeed possible that she escaped becoming HIV-infected despite having unprotected sex with you for eight months. The main reason is that not every HIV exposure leads to HIV transmission. The CDC estimates that the per-act statistical risk for receptive penile-vaginal sex with a male partner confirmed to be HIV positive is 10 per 10,000 exposures! However, please note this statistical risk is the same for every exposure. Consequently HIV transmission could occur with a single exposure. It's a bit like playing the lottery. Or perhaps a more accurate analogy would be sexual Russian roulette, because the consequences of "winning" can be catastrophic. I should also mention your wife will need follow-up HIV testing at the three- and six-month marks from the date of her last exposure (unprotected sex) to confirm her HIV-negative status.

As for when to begin antiretroviral therapy, this is a personal decision that has many variables to consider, including your degree of immune deterioration, viral load, desire to begin treatment, risk of medication side effects/toxicities, etc. The guidelines for beginning treatment are always in flux as we learn more about the pathogenesis of HIV and as new less toxic, more effective anti-HIV medications become available. I'll reprint below some information concerning when to consider beginning treatment below. I should also point out one potential extenuating circumstance for you. Your wife is (at least so far) HIV negative and you have an extremely high HIV plasma viral load, which means you are highly infectious. If you were to begin antiretroviral therapy now and drive your viral load to undetectable levels, the chance of HIV transmission would decrease significantly. I would suggest both you and your wife read through the chapters in the archives devoted to magnetic couples (one poz, one neggie) and HIV sexual prevention. I'll also report below some information from the archives on harm-reduction strategies for magnetic couples.

Good luck to you both.

Dr. Bob

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).

Tired (WHEN TO START TREATMENT, 2009) May 31, 2009

Hi Dr Bob. 2 weeks ago i had a routine blood test whch gave low neutrophile counts 1.200 X mm3 an d low Hb 11 and Hematocrit of 34 I got concerned and had an HIV test, this came back positive. My viral load is 6.000 and my CD4 257, the Dr says I must start treatment, is this correct? Besides feeling a bit tired sometimes, I feel fine. Thank you Paco

Response from Dr. Frascino

Hello Paco,

I'm sorry to hear about your recent diagnosis. If indeed your CD4 count is in the middle-250 range, I would strongly suggest you begin combination antiretroviral therapy without delay. Since this was your first test, if possible I would recommend repeating your CD4 count and HIV plasma viral load and also obtaining a resistance test (genotype). This will allow for confirmation that there was no laboratory or clerical error. Plus, the resistance test will help in selecting the best medications to include in your first regimen. I'll reprint some information from the archives that discusses beginning treatment. I would also suggest you read the information in the chapter "Just Diagnosed" that can be easily accessed on The Body's homepage. From there you can proceed to review the wealth of other information on this site.

Good luck. I'm here if you need me, OK?

Dr. Bob

Should meds be NOW considered? (WHEN TO BEGIN TREATMENT) Dec 26, 2008

Hello Dr. Bob.. Happy Holidays.. and may your coming year be as bright as a shining star.. I recently did my labs on received my results..CD4..453 and viral load 44,000. I have some minor discomfort such as swollen lymph nodes in the groin area and infrequent joint pains in elbow and knees. Do u recommend and consider the start of ARV treatment? Please give me your feedback because I am getting worried whether my immune system is rapidly degenerating.

Response from Dr. Frascino

Hello,

The optimal time to begin antiretroviral therapy remains a hotly debated topic as we learn more about HIV pathogenesis and natural history and develop new, more potent, less toxic medications. I'll try to give you an update on where things stand at the moment, but I would strongly suggest you discuss your situation with your HIV physician specialist, as there are many variables that must be taken into consideration for each individual situation. There is no one right answer for everyone. When it comes to beginning antiretroviral therapy it's a case of "one size fits one!"

A new study presented at the recent AIDS meetings in Washington, D.C. suggested HIV-positive folks should begin antiretroviral therapy sooner than the guidelines currently recommend (CD4 count of 350). The large study found that delaying the start of treatment until the CD4 count falls to 350 nearly doubles the risk of death during the next few years when compared to the risk of death in patients who began treatment earlier (CD4 count under 500). The survival benefit, however, must be weighed against the chances of drug toxicities and side effects. There is also the risk that poor regimen adherence could breed a drug-resistant strain of virus. There are, however, now three recent studies all showing that HIV-positive folks who begin antiretrovirals while CD4 counts are above 350 have a better chance of their counts returning to the normal range (600-1,200) than those who delay treatment until the CD4 count falls below 350.

Personally, as an immunologist, I strongly recommend early intervention with antiretrovirals if the person is ready, willing and motivated to begin taking the medications.

I should also mention there are situations in which we currently start antiretroviral therapy immediately despite CD4 cell counts. These conditions include patients with concurrent hepatitis and certain types of kidney disease and those who are pregnant.

Ultimately, I'm confident there will come a day when any HIV positive patient diagnosed will be advised to begin antiretroviral therapy as soon as they are diagnosed. This year we've seen treatment guidelines for beginning antiretrovirals increase from a CD4 count of 200 to 350. I think it's likely that this trend will continue with a formal recommendation to consider treatment at a CD4 count of 500 in the near future. Stay tuned to The Body. We'll keep you posted as the guidelines are revised. My personal recommendation is to begin antiretroviral therapy as early as possible in most situations, being fully cognizant that there are risks involved and that our scientific knowledge is still incomplete.

Hope that helps.

Dr. Bob

Shingles Starting Treatment & Queen Issues (SHINGLES AND HIV, 2009) (WHEN TO START ANTIRETROVIRAL TREATMENT, 2009) Feb 18, 2009

Hi Dr Bob, Three weeks ago I came down with Shingles. A small patch on the back of my neck and a little across my chest all on the left side. I went to my local GP and he gave me Valtrex ( the 7 day shingle pack)Since then the pain has gone and the Shingles have crusted over ...yet are still present albeit not as visible. Ive been POZ since 20th july 2007 and am NOT ON HAART....do you think having Shingles is a sign that my CD4T cells have fallen below 500??? I have a meeting with my HIV Dr in 1 months time for my usual LABS (cd4 & viral load) Do you think if my CD4 T cells have fallen below 500( even though experts say below 350) i should start treatment?

Also im seeing dark circles appear under my eyes...Im 33 yrs old ..is this simply age related or Low CD4 T cells and high viral load?? I drink plenty of water and have no family background of "dark circles /bags " under eyes...maybe its AGE ..aaarrrggghh And Mardi Gras is only a few weeks away...HELP!?!?!

Thanks, Drew (Sydney, Australia)

Response from Dr. Frascino

G'day Aussie Drew,

Relax mate! Approximately 95% of healthy adults are seropositive for varicella zoster virus (VZV), the virus that causes shingles. Of this 95%, about 5% of healthy adults develop zoster (shingles). The risk for those of us with HIV is between 15 and 25 times greater. However, getting shingles (unlike many opportunistic infections) does not correlate with CD4 counts.

As for what your next CD4 count and/or HIV plasma viral load will be, I really have no way of predicting. (I don't know what your previous counts have been.) It's a good idea to wait a month or so after an intercurrent infection (like shingles) before checking your counts, because viral loads may well rise transiently and CD4 counts fall transiently as a consequence of any infection.

As for the optimal time to begin antiretrovirals, having just returned from the HIV/AIDS meetings in Montreal, I can advise you this topic continues to stimulate lively debate among HIV specialists. Recent studies, such as the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), which included more than 8,000 patients from 22 North American prospective clinical cohorts, are designed to answer the question of when to start therapy. The investigators in this study found a 70% greater mortality in patients who deferred beginning treatment until their counts dropped to 350 compared to those who started treatment with counts between 350 and 500. This study was an "observational" cohort study and therefore there is the possibility of selection bias, etc. However, the results are certainly intriguing. It's also worth noting there are now several other studies that have also found lower mortality, morbidity, drug toxicity and/or improved CD4 counts with initiation of antiretroviral therapy at CD4 counts above 350. Current guidelines, as you mention, recommend treatment for all patients with CD4 counts below 350. However, with results of large studies suggesting earlier treatment is better coupled with the recent approval of new and novel antiretroviral therapies which appear to be better tolerated, less toxic, more convenient and less risky if adherence is not perfect, the treatment pendulum certainly seems to be swinging back in the direction of early intervention. Personally, I encourage earlier intervention if the HIVer is willing and motivated to begin. Ultimately, I think we'll be discussing "when not to start" rather than "when to start" treatment.

Would I recommend treatment if your counts are 500 or less at your next blood draw? I certainly would discuss the option of starting with you to ascertain if indeed you were ready, willing and motivated to do so. If so, yes, I'd recommend you start.

As for the dark circles, no, that's not HIV related. You've just probably had too many Fosters at the pub plus too many late nights at the Midnight Shift.

Enjoy Mardi Gras, Drew. I've got plenty of fond memories of the many Sydney Mardi Gras that I attended! I've even toyed with the idea of heading to Oz for this year's party as well. (Save me a dance, OK?)

Dr. Bob

condom failed (HARM REDUCTION STRATEGIES FOR MAGNETIC COUPLES, 2009) May 27, 2009

I am an hiv neg. female, my boyfriend has been hiv pos. for 20 years.and his viral load has always been undetectable.3 nights ago,after sex, we realized the condom had come off and was still inside me,it took some digging, but he got it out.and it was evident that he had come inside me.. afterwards, i started spotting, and started my period the next day. wich has me concerned.i get tested every 4 to 6 months, and had just been tested a week before..i am not going to get all stressed out about it,i know nothing is ever 100% safe,and it can only make things harder. but, the fact that i was bleeding a little has me worried.. how likely is it i've been infected ?, and how long should i wait to get tested again?.this is the first, and hopefuly the last accident we have had.!!

Response from Dr. Frascino

Hi,

Condom failure does place you at some degree of risk for HIV. That your positive boyfriend has an undetectable HIV plasma viral load would significantly decrease the risk of HIV transmission. However, your spotting may increase the HIV-transmission risk. In situations where there has been a significant HIV exposure, post-exposure prophylaxis (PEP) would be warranted if it can be started soon and no later than 72 hours after the exposure. Your exposure was three nights ago; consequently, this is no longer an option for you. But I would encourage you and your boyfriend to review the information about harm-reduction strategies for magnetic couples in the archives of this forum. We have an entire chapter devoted to magnetic couples. I'll reprint below a sample of what can be found there. At this point we would recommend you have an HIV-antibody test at the three- and six-month marks. The six-month test is recommended by the CDC because you had a significant HIV exposure from a partner confirmed to be HIV positive.

Good luck. I agree getting all stressed out won't help!

Dr. Bob

Undetectable Viral Load in Semen MAGNETIC COUPLE SEXUAL RISK 2009) May 26, 2009

A "big G'day" from Australia to you, Doctor Bob!

I am an HIV positive male involved in a relationship with an HIV negative female.

I have been on Atripla (or the Aussie equivalent) for a year now, and for 10 of those months been undetectable.

My girlfriend and I always practice safe sex - I wouldn't put her at risk for anything!

However, during sex last night, the condom broke. We were unaware that it broke and probably had vaginal intercourse for about 15 minutes before realising it had snapped.

I did not ejaculate inside her, but (obviously), can't tell you how much pre-cum would have "leaked" during this 10 minute period.

What are the chances she would have contracted HIV from me?

We are both frantically worried about it and it is putting a strain on our (otherwise wonderful) relationship.

I have read that a recent Swiss study found that a consistent undetectable viral load in the blood correlated with the semen, but I have read other reports that say this might now be the case.

I am hoping that being undetectable and not cumming inside her stacks the odds well and truly in her favour. What would be the chances of her contracting something from this one-off incident?

Thanks if you can shed any light on the matter, and good luck to you and your partner in your own magnetic relationship - opposites attract!!

All the best, Oz Boy. xx

Response from Dr. Frascino

Hello Boy from Oz,

Here's what we know:

1. The HIV plasma viral load usually, but not always, correlates with the HIV viral load in semen (or cervical secretions).

2. Having an undetectable HIV plasma viral load significantly decreases the chances of HIV transmission.

3. Not ejaculating in the love canal significantly decreases the chance of HIV transmission.

4. PEP (post-exposure prophylaxis) taken as soon as possible and no later than 72 hours after an exposure can decrease the chance of HIV transmission. (You can read much more about PEP in the archives.)

To specifically answer your question, the odds are very much in your girlfriend's favor. However, HIV testing is still warranted. I would also recommend you and your gal-pal review the harm-reduction strategies available for magnetic couples (PEP, PrEP, proper condom use, etc.). I'll reprint below some information from the archives. Please note we have an entire chapter devoted to magnetic couples.

Good luck from one magnetic couple to another! Magnetic couples rock!

Dr. Bob

Hiv infection? Magnet couple stress and fear (MAGNETIC COUPLE SEXUAL RISK 2008) Oct 8, 2008

I am negative at the moment and my boyfreind is HIV positive. he is an HIV educator actually.

After I accepted his status, we finally became intimate with each other. I did oral sex on him 3 times that night. Twice on his penis and once with his ass. He precums almost instantly (I don't know if its just with me lol), but I feel like despite the wealth of knowledge about the risk of unprotected oral sex I feel like I may have exposed myself. I didnt not swallow much if any precum. I had a little after taste and I mouthwashed mid session. I only have minor gum bleed after toothbrushing. I am a little concerned about anal oral intercourse too even thought I saw no possible way i could get infected. He penetrated me with a condom and i am not concerned about infection there.

I just want to feel a little assured about my chances for infection here. I love him so much and I find it hard to be intimate with him without thinking about his status. It's a reason why I can't put myself in a condition to penetrate him. And I feel horrible even thinking about talking to him about it because he is an HIV educator and probably know more than most about safe sex practices. Gawd, Just thinking about it and letting my mind run amok about possible infection makes me want to cry becasue I dont want to hurt nor loose him, but I want to trust him with us and our intimacy. And I want to be able to give him my all when we make love without holding myself back.

Given what I said, what were my exposure risks. And what advise do you have for me and the relationship with the one i can see myself with forever?

Response from Dr. Frascino

Hello,

Your HIV-acquisition risk is extremely low. There have been no documented cases of HIV transmission due to rimming or getting rimmed. Oral sex carries only a very slight risk for HIV acquisition/transmission. You can read much more about this in the archives of this forum. We have entire chapters devoted to oral sex and sexual-HIV transmission risk.

Regarding your concerns about sexual activity within a magnetic relationship, as you might imagine, you are not alone. It's something all magnetic couples must come to terms with. Communication is key and that is what is lacking in your current relationship! That your Mr. Right is an HIV educator should make communication easier, not more difficult! Chances are he's as worried about infecting you as you are about acquiring the virus. The two of you are overdue for a heart-to-heart (note that's heart-to-heart, not hard-to-hard) talk! You need to openly discuss your concerns and together the two of you need to develop sexual rituals based on what is known scientifically about the HIV-transmission risk and on your individual levels of comfort. I suggest both you and your Mr. Wonderful read through the chapter in the archives devoted to magnetic couples. You'll soon see your concerns are shared by many of us in serodiscordant relationships. In addition to taking equal responsibility to make sure HIV is not transmitted, there are a number of other measures the two of you might want to consider to further reduce transmission risk:

1. Have your poz-partner take antiretrovirals to drive his HIV plasma viral load down to undetectable levels. This will significantly decrease transmission risk.

2. Get a starter dose of PEP (post-exposure prophylaxis) to have on hand just in case there is an accidental exposure (condom break).

3. Consider PrEP (pre-exposure prophylaxis). This involves the negative partner taking antiretroviral medication prophylactically on a routine basis. We still don't know if this approach is effective. Clinical trials are underway. Some magnetic couples aren't waiting for the results of the trials, but rather are instituting PrEP as a harm-reduction strategy now.

You can read much more about PEP, PrEP and other risk-reduction strategies in the archives.

Finally, I want to assure you from personal experience that opposites attract and that happily-ever-after can indeed become a reality for magnetic couples. Steve (Dr. Steve, the expert in The Body's Tratamientos forum) is HIV negative. I'm "virally enhanced." We've been happily-ever-aftering for 15 years and yes, that includes toe-curling, wake-the-neighbor, own-name-forgetting fusion sex. My advice to you is to make sure Mr. Right doesn't get away for all the wrong reasons.

Good luck to you both!

Dr. Bob

cd4 counts (WHEN TO START TREATMENT) Oct 2, 2008

Doctor,

i've noticed over the years (in fact over the course of a few short months), you've recommended med treatment at higher and higher cd4 counts. First, it was 200, then 250,... now, all of a sudden you're telling people that medical consensus says a whopping 350! What gives you the right to simply just keep rounding up and up and up, when you are advising people.

Other doctors here assure the reader that even if the person starts meds late, they can eventually get a good response.

If you're gonna say 350, cite your source,... and i hope its more than just a lone wacko doc you heard at a symposium in Mexico.

oh, and i'd love to see a control study of mortality comparison between someone on meds at whatever cd4 count verses people who never go on the meds.

Response from Dr. Frascino

WHOA! Calm down there hothead! First thing I want you to do is take three big cleansing yoga breaths. Go ahead. We'll wait. There, now don't you feel better and, hopefully, a bit less confrontational?

"What give you the right to simply just keep rounding up and up and up, when you are advising people?" Hmm . . . well, for starters, I'm the HIV physician specialist whose role is to advise (usually polite) questioners about HIV-related medical scientific facts and evolving medical treatment guidelines, based on a thorough review of peer-reviewed clinical trials and over a quarter of a century of personal experience treating thousands of patients with HIV/AIDS.

"Other doctors here assure the reader that even if the person starts meds late, they can eventually get a good response." In general I do not disagree with this statement and I have given similar advice many times. However, depending on when someone starts and many other variables (concurrent infections, host immune integrity, viral strain, adherence, tolerance, drug resistance, etc.), the more accurate statement would be ". . . they MAY eventually get a good response." There are no guarantees. And certainly there is absolutely no evidence suggesting that starting later (lower CD4 count) is better than starting earlier (higher CD4 count). In fact, there is growing scientific data suggesting just the opposite!

"If you're gonna say 350, cite your source . . . and I hope it's more than just a lone wacko doc you heard at a symposium in Mexico." I'll be more than happy to cite references (see below). As for "a lone wacko at a symposium in Mexico," I assume you are referring to the International AIDS Conference held in August in Mexico City and attended by nearly 30,000 scientists from around the globe. It was a bit larger in scope than a "symposium" of lone wackos.

Regarding your desire to see a "control study of mortality comparison between someone on meds at whatever CD4 count versus people who never go on meds," that clinical trial will never be done going forward, as to do so would be highly unethical based on what we know about antiretroviral therapy. Besides, the information you desire can be collected historically by looking at the morbidity and mortality data collected prior to the development of effective antiretroviral therapy (mid-1996). What you would clearly see, if you took a look, is that there has been what can only be considered an astounding and miraculous decrease in both morbidity and mortality since mid-1996 when HAART (highly active antiretroviral therapy) became widely available following the International AIDS Conference in Vancouver (another "symposium"?). For historical perspective, Netflix the PBS documentary "Age of AIDS." It chronicles the first 25 years of the pandemic. You could also try reading Randy Shilts's book "And the Band Played On."

As for why HIV treatment guidelines keep changing, please note this is an evolving epidemic. We continue to learn more and more about HIV pathogenesis and the natural history of the disease. In addition, as noted above, there have been (and continues to be) remarkable progress in developing new and novel approaches to treating HIV disease. In 1998, the U.S. Department of Health and Human Services created a panel of physicians, researchers and consumers to develop treatment guidelines. They constantly review AIDS research results. The treatment guidelines are updated almost annually based on the ever-evolving scientific and epidemiological data. The panel released the latest guidelines update in January, 2008. These are guidelines, not rules! All patients need individualized care from competent and compassionate HIV physician specialists. When it comes to HIV treatment, my motto is "One Size Fits One!"

To review the most recent and well referenced! guidelines from the U.S. Department of Health and Human Services (128 pages!!!), you can download a full copy at http://img.thebody.com/hivatis/pdfs/adult_guide.pdf. Check it out Mr. Hothead.

As for citing my references, please review the "SMART" study results. The Strategies for Management of Antiretroviral Therapy (SMART) Study Group was conducted in 318 international sites in 33 countries. A subset analysis of this study showed starting antiretroviral therapy at a CD4 count above 350 the current threshold for starting therapy based on the guidelines reduced risk of serious illness and death compared to beginning treatment later. (The full report is in the April 15th edition of the "Journal of Infectious Diseases.")

Current treatment guidelines in Europe and the U.S. recommend deferring antiretroviral therapy (ART) in asymptomatic adults until the CD4 count falls to 350 cells/mm3 or, in resource-poor countries, 200 cells/mm3. These recommendations were based on the results of nonrandomized studies and expert opinions.

The guidelines were formulated based on earlier concerns about the risk/benefit ratio of starting ART earlier and the fact that AIDS-defining clinical events (opportunistic infections, malignancies, etc.) were rare at higher CD4 counts. There were concerns that any benefits of early ART might be outweighed by toxicities, long- and short-term side effects, cost-effectiveness, quality of life issues, adherence and the development of drug resistance.

There is now an impressive and growing body of evidence to suggest that these guidelines should be revisited. First, data from clinical trials indicate that the risk of AIDS persists at CD4 counts greater than 500 cells/mm3. Second, even in patients with high CD4 counts, the risk of AIDS or death decreases with the initiation of ART when compared with that of those who are not on ART. Finally, the risk of serious non-AIDS-related diseases and cancers is lower at higher CD4 counts!

I could continue on and on about epidemiological reports from resource-poor countries where large numbers of HIV-infected individuals do not have access to ART. Tragically their morbidity and mortality figures are identical to what we witnessed here in the U.S. prior to the development and availability of potent effective antiretroviral therapy.

So, please continue to believe whatever you wish, but if you plan to ever return here with a question or problem, I strongly suggest you begin with an apology and ask your question in a more polite (or at least amusing) fashion.

Dr. Bob



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