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Decisions, decisions....

Dec 5, 2001

Dr. Young, First, thank you for taking the time to consider my situation. I had an indeterminate test result on October 30th. I followed that with a viral load test and learned that my VL is 4,070 and my CD4 count is around 511. I have tested negative every six months prior, so I am certain that I am a recent seroconversion. I have been to two doctors, both of whom I feel confident with. However both have different takes on my situation. The first doctor suggests that I not do anything until my numbers change sometime down the line. The second doctor believes I might benefit from STI, thus preserving some of my natural immune function. He believes that becasue I am so recently seroconverted, I might have a unique window of opportunity. I am a proactive person by nature, but all my friends who are positive are discouraging me from pursuing meds just yet. I'd like to make a decision and wonder if you could offer any insights. Also, if I were to start meds, would I be jeopardizing my future options? If I were to start and stop sometime down the line, would I have done irreperable damage? Thank you for taking the time to respond.

Response from Dr. Young

Thanks for your questions.

I agree that it would appear that you are in that seroconversion period. This situation is relatively unique wiht regard to HIV treatments; recommendations about starting treatment here are different that during established (or chronic) infection.

Starting therapy during acute seroconversion seems to have some interesting, and important benefits that do not seem to occur later in disease. First, the immune system response to HIV appears to be much better preserved. Indeed, only limited HIV-specific immunity is recovered among persons who start therapy with even intermediate stage disease (see: ACTG315). Secondly, after discontinuation of therapy started during acute infection, the viral loads observed seem to be much lower than expected-- for a very few persons, their viral load is actually undetectable. Since viral load setpoint appears to be an important determinate of the rate of disease progression, having a lower load even early in infection should have important prognostic implications.

Lastly, there is the well publicized data about STIs during acute infection. This data would suggest that structured treatment interruptions might be a possibility for acute infection; exploiting the above concepts and perhaps using one's own virus as a vaccine to enhance immune response.

It is important to recognize that most of what I have talked about remains the subject of intense research. These ideas are not validated by large clinical studies yet and the best way to further our knowledge about acute infection would be to consider enrolling in clinical trials.

The decision to start antiretroviral therapy, however, should be made in close discussions with your doctor. The concerns about adherence, side effects and toxicity (like drug resistance) are not eliminated when one starts therapy during acute infection. Indeed, if there are significant issues that might impair adherence, for example, then it would be very reasonable not to start treatment now.

Lastly, for those who do start treatment during acute infection, the decision to start does not necessarily mean that you will be taking these medications forever. Actually, given the above discussion, the hope would be that with a better understanding of the how's and when's that we could stop treatment after a period of time.

Hope that this is helpful. Good luck, BY

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