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Ok, Mr. Dr. Al Cohen
Jan 21, 2002

Dear Al: Should an infected person start HIV meds within a year of infection? My HIV+ girlfriend says "no" and should wait until CD4 cells hit 350. And should we use condoms since both are infected? Thanks Al, Bo Bo

Response from Dr. Cohen

OK Mr o Bo. (Assuming you prefer first names with the first letter deleted?) Here goes.

Starting treatment within a year of infection vs waiting is not an easy choice to just simply pick the winner of these two -- as there are pros and cons to both. Why start soon?? There are a few issues here to consider. First - those who are diagnosed with HIV very soon after infection - like a few weeks to months after - may have a special opportunity to preserve certain cells in the body that are engaged in the initial battle to control HIV. And there is some suggestion that those who do treat in those first few months can protect and rescue those cells, and in time, these cells may eventually be helpful in maintaining longer term control of HIV perhaps with less time needed on medication. But these cells are among the first targeted for destruction by HIV - and so treatment after say, six months, may be not much different in terms of this issue than is waiting six years. The window of opportunity may be narrow. Assuming that you are not asking about that window, then lets go to the next issue.

When to start is based on a few key ideas. The basic decision however, comes down to starting treatment at that point before any irreversible damage is done by further delaying treating. Since there are some side effects to treatment. Like the initial possible side effects of pills (things like diarrhea, rash, upset stomach and so on), and then for some, longer term complications as well from meds (like body shape changes, changes in blood cholesterol and so on). Given the possible side effects, there is increased discussion about how to minimize the side effects caused by meds by, in part, delaying starting on them until just before any "irreversible" damage is done. Which makes sense of course. IF we knew when that was.

But here we are still learning. As there may be some irreversible damage done from day one on - and that leads to at least the feeling we should treat as soon as someone is ready to start. But in terms of the information and studies done, if someone prefers to wait, studies suggest we can wait to even a CD4 count close to 200 before starting - since those who delay until then seem to do fine, at least so far as we know now. Delaying until the counts drop to below 200 is not recommended - we think our meds can help prevent significant and important illnesses that happen when the counts drop that low. And that we have enough meds to make treatment attractive and worth it.

But how far above that count of 200 to start meds is an ongoing debate - and there are studies that are underway to help answer this. Until they're done, it will be a judgement call. Including your own judgement.

And so - one way to help decide - is to look at what it would take to be on meds. A discussion with a clincian about a combo of meds you might take. Take a look at a combo. If you have never taken pills - try it. Like start taking some vitamins at the same time and schedule as a combo. We can make treatment pretty easy for many - like a few pills once or twice a day. And then give it some thought about how ready you are to take these every day for months if not years... since if you are not ready yet - most of us would say you should wait - since missing doses is a very good way to create premature drug failure. And we think those who are ready will avoid much of this cause of drug failure. And that "ready moment" is worth waiting for if your counts allow you to wait -- given we are talking about treatment for the next several decades... in order to keep someone healthy for a long life.

So in sum, if you are ready for meds, just don't feel right by waiting, have any symptoms that might be HIV, then you can start now. Regardless of your counts. If you prefer to wait - to a count of 350 or even lower - you can. Both are reasonable choices that you need to make -- given both might get you to the same place - a long and healthy life. And depending on where you are - there are studies that are comparing starting now versus delaying - you may wish to join one to help answer this ongoing debate. One such trial happeing in a few countries is described on a web site - www.smart-trial.org - and there are others as well.

As for condoms - the assumption that leads us to suggest condoms are still important comes mainly from info about the transmission of resistant strains between partners. If for example, she had a strain of HIV that was resistant to a certain drug, and you don't already that resistant HIV - that drug can still be very useful to you. If you then get infected by this resistant strain, it is possible you'd lose the benefit of specific treatments as a result. So protection makes sense for that reason. As well as the desire to avoid any other sexually transmitted infections one of you has and the other does not have. But the issue of HIV transmission is a controversial one -- researchers are still exploring this in several studies. So until the studies are done, you may want to again review the specifics with a clinician who is expert in HIV and can talk with you both about the specific pros and cons as they apply to you and what is happening with you both.

Hope that clarifies o Bo - if not write back -- K?



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