If I Were HIV Positive

It's really accumulating now to the point that says earlier treatment is the best way to deal with this disease, because most of the damage of HIV is really done in those first few months. After that, people go for long periods where they're relatively stable. But that underlying damage has been done and the patient is going to pay the price for it sooner or later down the road. So I think the best thing you can do is get into treatment and try to stop that as quickly as possible.

If you didn't start early and you just happened to get tested and you think you were infected a couple of years ago, what CD4 count would you start treatment at?

I wouldn't base it on the CD4 count anymore. I would base it simply on the fact that I was positive. Unless I had a spectacularly high CD4 count and naturally controlled virus -- meaning undetectable despite no use of treatment -- if that were the case, maybe I would delay treatment. That would mean I'm one of those what they call elite controllers. But the people are rare and few and far between.

For most other folks, the right answer, I believe -- and this is just my personal belief, of course. I'm not recommending anything for anybody else -- but my personal belief is people ought to start treatment simply based on the fact that they're HIV positive.

Just to clarify: What do you mean by high CD4 count?

In the context I was referring to, I was talking about 1,000 or above.

What would be your first choice of a regimen?

The standard first choice these days is something like Atripla [efavirenz/tenofovir/FTC], which is a simple three-drugs-in-one pill. I'm not sure, though, that it's the least toxic regimen out there.

If I had the choice myself, I would probably start with the new drug, the integrase inhibitor Isentress [raltegravir] because everything I've seen suggests it's both the most potent and the least toxic drug that we have. At least temporarily, I'd couple it with Truvada [tenofovir/FTC], which is a two-drug combination that's probably the safest of its type.

But I would continue to watch carefully, because there are studies underway now that are looking into the possibility of using just two drugs of the new generation. Two drugs that have high potency and very low toxicity. We don't yet have all the data we need to do that, but it's coming soon. So I'd start with the Isentress and Truvada and then I'd watch.

Would you worry about metabolic side effects?

That's exactly the reason I would choose what I did. There don't appear to be metabolic side effects with Isentress. It has no apparent effect on cholesterol levels, which is really sort of at the heart of the metabolic effects. That's precisely why I would choose it. Almost anything else that you choose, like a protease inhibitor or even the non-nucleoside [NNRTIs] like Sustiva [efavirenz], they do have an effect on cholesterol and the metabolic effect.

One protease inhibitor that doesn't is Reyataz [atazanavir]. But that's only if you use it without the booster drug ritonavir [Norvir]. Unfortunately, to get it to work well, you really need to use ritonavir with it.

There are some studies going on, or starting soon, that are going to combine Isentress and Reyataz without the booster. Those will be very interesting to watch because there you'd have two drugs that don't have metabolic side effects.

Would you take any additional vitamins or supplements if you were positive?

It somewhat depends. There's a lot of growing literature these days that suggests that vitamin supplements are not having the effects that people had hoped on heart disease and other factors. There had been a lot of hope that it would affect cancers and heart disease and diabetes. The long-term data is not supporting it.

But it comes down to your diet. If you eat a good diet and you take care of yourself, then I don't think the supplements are all that necessary. But if you don't, then they're probably better than nothing and then I'd consider them. That's about all I can say on that.

I think that there is still some evidence suggesting that if you start during acute infection, there may be a benefit, even if it's a temporary course of treatment. That means starting when you're still having your fever and you haven't even gotten a positive antibody test yet.

If I were diagnosed in that phase -- and very few people are, sadly -- I would probably start HIV treatment right away and then when the dust settles decide what to do about it for long term.

If I was diagnosed maybe a month after infection, I think the data are a little less convincing that there is any special benefit, but I still think the question is an open one. Since I live in Baltimore and we have a primary infection study that randomizes people to either a year's worth of treatment or to just wait until they meet the standard guidelines criteria for treatment, I would think I would enroll myself in that trial. Because we simply don't know if there's any special benefit once you've seroconverted and then recovered from acute retroviral syndrome.

The other question that you didn't ask, but it's relevant, is: When would I start just based on being infected irrespective of when I acquired the HIV?

I think that we're moving toward treating just about everybody with HIV. The data continue to show -- granted, they're observational data -- but they continue to show that there are differences in morbidity and mortality in treated patients versus untreated patients regardless of CD4. We recently saw the data from NA-ACCORD showing a 70 percent lower mortality in people who started at 350 to 500. I suspect in CROI [Conference on Retroviruses and Opportunistic Infections] we're going to see further data supporting treatment above 500.

Ultimately, I think we're going to get to the point where we just say, "Why would we not treat this infectious, progressive, transmittable disease when we have such good, safe therapy? Then the questions really come down to cost effectiveness and cost. How are we going to afford treatment? But I think from a medical standpoint you can certainly justify it. I think if we get to that point, the reason not to treat will be primarily in people who are unlikely to be able to adhere to therapy. In those people, it might make sense just to wait.

I think if I had HIV, regardless of when I thought I was infected, I would be tempted to just go ahead and start treatment.

What would be your first choice as a regimen?

Right now, probably Atripla [efavirenz/tenofovir/FTC]. My kidneys are okay and I would be curious to see what the dreams were like. [laughs] I think there are always people who try Atripla and don't tolerate it even after giving it a month or two of a good trial. You can never predict who those people are going to be in advance. All you can do is give it and find out what happens.

But I think the combination of the simplicity of it and the fact that, so far, it's really never been surpassed in terms of efficacy in any clinical trial would be pretty convincing. But there are certainly plenty of other great options that I could fall back on if that didn't suit me.

Would you worry about metabolic side effects, body shape changes, things like that?

We don't worry about that with those drugs so much. The lipoatrophy was really a function of the thimadine analogs, AZT [Retrovir, zidovudine] and d4t [Zerit, stavudine], which I don't use anymore [for my patients]. The fat accumulation is -- it's less clear what causes that. It doesn't seem to be a direct side effect of antiretrovirals or protease inhibitors, specifically, but it may be a secondary effect of drugs like protease inhibitors that can cause insulin resistance or high triglycerides, which then in turn can lead to fat accumulation. Atripla doesn't include a protease inhibitor, so I'd be less concerned about that.

Certainly, we see a lot of weight gain in people who start antiretroviral therapy of any kind, but you have to distinguish that from fat accumulation. The weight gain is just because you're getting healthier and when you get healthy it's easy to gain weight. I have to remind people about that even before I start them. They may read about body shape changes, but just overall weight gain is not really a body shape change. You're just restoring yourself to normal health and that allows you to gain weight more easily that you did when you had a high viral load.

Would you take any additional vitamins or supplements?

You know, the evidence for vitamins and supplements is pretty weak right now. In fact, most of the vitamins are getting pretty bad press with new studies showing that they either don't do the things they were supposed to do or that they do things that they're not supposed to do.

I eat a pretty healthy diet, so I don't think that I'm deficient in any vitamins. I certainly recommend vitamins for people whose diet isn't so good. The only vitamin right now that's got a pretty good reputation is vitamin D. Especially for people who are living in the Northeast or the Northwest, not getting a lot of sun, using sunscreen and all those things they tell you to do and then you get no sun exposure, so you become vitamin D deficient.

I do think that taking vitamin D and calcium supplements probably makes some sense, but in terms of other things, I'm not sure that there's much evidence to support it, though a multivitamin is probably pretty harmless.

So you don't think the data supports starting HIV treatment during acute infection?

I'd only do that if I was really sick or I developed an AIDS-defining illness during the acute seroconversion. Otherwise, I wouldn't do that, no.

Would I do it if I knew I got infected three days ago, or four days ago? In that case, I'd join a clinical trial; I definitely would. Or I'd find somewhere where they're doing work on that, and I'd go and volunteer, and I'd say randomize me.

If I was chronically infected and asymptomatic, I'd have to weigh up what's going on with my own individual health and my feeling about how to take treatment; I'd make an individual decision.

What would be your first choice as a regimen?

I'd probably take efavirenz/FTC/tenofovir [Atripla] actually, because in the U.K. [United Kingdom], we've got a lot of experience with non-nucleosides and with that combination. I would quite like to have a one-pill, once-a-day regimen to start with. I think I could stick to that, but obviously, if I got side effects, I would switch over.

Would you worry about metabolic side effects with these drugs?

Yes, of course I would. I'd worry about them, but I think that was the point I made here. If it's saving my life and preserving my health, I'd take them, but I'd make sure I was regularly monitored for those side effects. With the sort of combination I mentioned to you, I'd make sure my cholesterol was measured and my renal function was measured.