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Early treatment didn't work
Feb 1, 2003

Dr Cal, I was infected in March of 1999. I had a negative antibody test and RNA PCR of 6.7 million. I started HAART April 1 with a VL of 4.5 million and a CD4 of 428(26 percent). After 19 months I stopped meds for six months, went back on for three and have been off since August 2001. My labs since then:

Nov 19 11,800 482(25) Feb 20 11,200 605(24) Jun 24 28,100 586(23) Oct 01 26,500 531(21) Jan 07 24,500 468(21)

It looks like early treatment didn't do anything for me. Should I consider another round of treatment? How long before I HAVE to go back on meds? Thanks.

Response from Dr. Cohen

So let's start with what you mean by early treatment "not working". I assume you are referring to your viral load in the twenty thousand range, as opposed to some lower number?

What has been noticed in the early treatment studies is actually a few things. First is that some will have much lower viral loads when stopping therapy than expected - some do maintain a viral load of less than 5 thousand, and some lower than this. To get there - a few things were done - first was very very early treatment - and second were a series of stops and restarts to get there. After a series of these interventions we can state that some do have the outcome you imply - a lower viral load when off. But some don't have a very low viral load - some have one similar to yours for example. So did STI and early treatment "fail" for you?

The first point is that we can't tell what impact STI has. Meaning we cannot yet know what your viral load would have been had you not started treatment so soon after infection and just monitored. Perhaps it would have been 25,900 as it is now. Perhaps it would have been 256,000 as happens to some - and the STI brought you down by a log. Can't tell based on your experience and that of others. Similarly - your CD4 count is now pretty solid - no worries of illness at your counts and they've been stable for years without meds. That is certainly important and perhaps another part of the success you have.

We can certainly state that we have no information to guide us on whether repeated starts and stops for you will lower your viral load further. While work goes on in this field -we have no test we can order at this point to predict for whom such an approach will help or have no impact. Which means you certainly can try it - we just can't say what the benefits would be.

That said - you are in a pretty stable place for now. A place that all of our guidelines agree on as one that doesn't require treatment to protect you if you'd prefer to be off. And you might stay stable without meds for a few more years - even with that slowly rising viral load you describe.

There are good reasons for you to be back on meds - protect that immune system, grow some more cells, and try to bring your viral load lower with more STIs. On the other hand, there are good reasons to postpone meds - side effects and the like. Your situation is one that many studies are focussing on - for example there is one study comparing these two options in the largest trial ever attempted in our field. It compares going back on meds to postponing and retreating only when your body "needs" the help of these meds - which is around 250 cells. You can read more about it on the SMART web site.

So I'd say we can't be so certain early treatment didn't do anything - you are doing pretty well, and perhaps it deserves some of the credit. And as for retreatment - and having to go on meds - I'd say it is optional and studies like the one above are needed to answer your question - since we just ain't sure yet...



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