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WHEN TO INITIATE A THERAPY
Nov 26, 2001

HELLO DR. COHEN.I WOULD LIKE TO ASK ABOUT WHEN TO INITIATE A THERAPY.WHAT ARE THE BASES OF THE THERAPY TO BE INITIATED. HOW MUCH VIRAL LOAD AND CD4 NEED TO HAVE FOR TREATMENT TO START. IS ASYMPTOMATIC PERSON HAVE THE TENDENCY TO HAVE A HIGHER VIRAL LOAD OR A LOWER VIRAL LOAD? WHY SOME OTHER PEOPLE REMAINS ASYMPTOMATIC FOR MANY YEARS AND OTHERS DEVELOP AN HIV SYPMTOMS IN ONLY A YEAR? I WOULD REALLY APPRECIATE IT SO MUCH IF YOU WILL ANSWER THIS QUESTION.

Response from Dr. Cohen

Your question is one we have addressed here before - and can again. And there is also much written about the issues you raise - including lots of info here on this site archived in articles and summaries about when to start treatment. So let me be relatively brief here - and hope that it is just the beginning to your searches on here and elsewhere on line.

First - when to treat. The simple understanding is that HIV, when it grows, destroys our cells. The particular cell we focus on is called a CD4 cell, or T4 cell, or T helper cell - three different names for the same cell. This cell is key in protecting us from about 2 dozen different illnesses that we call AIDS. And if we don't stop HIV at some point, it generally does enough damage to these cells to allow these infections to happen at some point to almost everyone.

But that can take a while. Meaning, after initial infection, there can be a difference in the pace of damage done by HIV. For some the damage is very slow (even more than ten years), while for others, very fast. This difference is well described and is explained largely by differences in the Viral Load. This number is simply how much the virus is growing. And the more it grows, the more damage it does. So for someone with a high viral load, the damage is faster. Which means someone with a high viral load has a higher chance of getting sick from HIV - with one of the illnesses on the list we call AIDS - than someone with a lower viral load.

One analogy that helps some understand this is a car. The car is starting to drive on a road towards trouble... and the length of the road is the CD4 count - the more cells there are, the longer the road is until there is trouble. And the speed of the car is the HIV viral load - the higher the load, the faster the car is heading down that road... got it?

Now, when to stop this process. You would think that if there is any chance of getting sick from HIV at all, we would recommend treating it. And indeed, that is where we were as a group until the past few years. And if treatment were perfect, that is what we would still say. But in the past years, we have been struggling with the side effects of the meds, versus the benefits they bring.

So - it is clear that we can hit the brakes on this car - we can almost always stop HIV from growing, especially in someone just starting treatment. And that allows the car to not just stop but to back up - and regrow the cells that are lost. When to do this - and how to do this, and with what meds, in an ongoing discussion. The main area of agreement is to start meds before the CD4 count goes below 200 cells - since down below this there is a higher risk of illness. And to only start when you are ready to take meds. Since someone who starts, and is not ready to do what is needed in taking pills once or twice a day each day - can rapidly lose the benefits of these meds. And once lost, we lose much in the options we have to stop HIV.

Now, starting meds does not have to mean that you can never stop again - in fact, there are studies showing that people who start can stop at some future point. Indeed, this key observation has led to the funding of a trial in the US and Australia just getting underway - in which people will be randomized into two different approaches to treatment - one in which treatment is started and essentially continued, versus another strategy in which treatment is given in someone with a CD4 count below 250, and then stopped once the CD4 count is above 350, starting again when the count goes below 250. This newer approach is being tested to see if we can maintain a healthy count while using meds only on some days, not all days - to minimize the side effects while maintaining benefits. There is a web site - www.smart-trial.org - on which you can read more about this.

There is much more to say about this - it is a key issue for someone with HIV. But there is much progress. Where you live determines how many meds you have access to - here in the US we now have 16 different meds to work with. And this allows us great confidence that we can stop HIV. And do so with a med combo that almost all can feel OK on.

So I hope this clarifies some of the issues - and your reading is helpful in figuring out what this means for you...



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