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Choosing Your MedsChoosing Your Meds
           
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Why wait to start meds?
Aug 26, 2004

I have been positive for 10 yrs. At 3 yrs positive my viral load was 100,000 although my T4 was about 600. My MD said you have a choice, (negative side)deal with the side effects longer, possibly cut down later medication options OR (plus side) keep your immune system healthier for longer.

I decided to get on meds right away in 1997. I'm happy to say I've been + 10+ years, with a viral load consistently under 1000 for years and T4 over 650 always.

My question is WHY WAIT? Why is it recommended to wait until t4 is less than 350 or an astronomical viral load result. Both of these # means that HIV HAS ALREADY DONE damage to your immune system.

This question comes from a newly HIV+ friend of a friend who is asking me for guidance since I'm doing so well. But have been through hell with side effects.

No matter what, I think early start of meds was the right choice why wait until the damage has been done?

Response from Dr. Wohl

Ah, this is BIG the question. As you say, this is a balance. On one side of the scale put the benefits of therapy: mainly viral suppression and preservation of the T-cell population. On the other side lump side effects (short term and long), the risk of failure with resistance development and the cost of treatment.

If we had a drug that was very well tolerated, potent, durable, with little risk of resistance and cheap, we would be starting everyone on it at the time of HIV diagnosis. It is the shortcomings of current HIV therapies that has led to the cautious use of these agents. This caution is bolstered by data that indicate there is no difference in survival over 3 years, at least, among patients started at CD4 cell counts of 350 and above. Longer term follow-up may suggest that there are some differences between starting at a CD4 of 350 versus 450 but we have yet to see this.

Lastly, while you are correct that a person with a CD4 cell count of 350 has suffered damage to their immune system, reassuringly, studies of immune function demonstrate that HIV therapy started at CD4 counts of 200 plus rebuilds immunity very well.

So, in a nutshell, that is what must be considered when contemplating when to start HIV therapy. You did fine and made a great decision for your situation. Others have to do the same with all the available info and the advice of a good clinician.

DW



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