time for meds?
Aug 27, 2003
Hi Dr. Henry, Thank You in advance. I have been positive for 30 months with "no trend." I recently got labs back at:
300--t-cells 375 last year 51,000-vload 21,000 last year
I want to wait for next set of labs. Are you from the school of begin meds now or we can wait/holdoff? Do you think it is time for meds Your opinion?
Response from Dr. Henry
Good question for which I have no standard response. I try to individualize my recommendations in each case since each patient presents a unique combination of viral, immune system, genetics, person philosophy, other medical issues, etc. The new US guidelines favor starting treatment with a CD4 count < 350 cells/mm3 and/or a high viral load (> 100,000). There remains controversy about the CD4 cut-off. The 1-2 year risk for an AIDS event is low for persons with CD4 > 250 and viral loads < 100,000 especially if they are asymptomatic and the blood tests are not changing rapidly. The SMART trial now open in the US randomizes patients to a treat now versus wait until the CD4 count is < 250 approach. In my practice which sees many patients with unstable housing/chemical dependency/mental health/insurance problems, I try to stabilize their other problems often before focusin on HIV treatment. I often treat aggressively early (ofen with a Kaletra based regimen) with a high barrier to resistance and then switch to a easier/simpler regimen once the viral level is repeatedly < 50 copies/ml. I usually check a resistance profile. A recent study (2NN) suggested that Viramune and Sustiva are fairly similar when used in treatment naive patients though that remains contested. The regimen your doc recommended is an simple one that looks good on paper but for which there is relatively little data as of yet. Your trend in blood test results would usually lead me to recommend therapy sometime in the next 6-12 months-the timing is up to the patient. I usually inform patients about available clinical studies that are addressing issues that we need to learn more about. There is no urgency to start therapy in most cases so the timing I leave up to the patient= when they are ready. I am more likely to have confidence in a decision to treat when I have been following the blood tests closely for a while and the patient has made their appointments and voices interest/enthusiams in a decision to treat. KH
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