When considering therapy, there are many issues to keep in mind. Though research has not defined an absolute standard time to start anti-HIV therapy, some criteria can assist you in making a decision tailored to your needs. This road map highlights these criteria and may help you in this process. It may be a good idea to bring this with you to your doctor's appointment for discussion. Remember, take your time and don't feel pressure to make the decision today.
Your Readiness and Belief in Therapy
Before you start any kind of medical treatment make sure that you're ready. Take time to reflect and contemplate how taking therapy is going to impact your life. Ask yourself questions like: Do I feel ready? What kind of expectations do I have? Do I have a support system or someone I can talk to about therapy? Am I scared? If so, of what am I afraid? Explore your own beliefs and fears about therapy. Ground yourself in knowledge rather than fears. Talking to other people about their treatment decisions can be extremely beneficial, but remember . . . what works for one person does not always work for another.
What is your viral load?
Has your viral load trend:
- gone up more than three-fold (i.e., an increase from 10,000 to 30,000); or
- gone down over your last few tests?
30,000 or Below (Generally Considered Low)
Therapy is generally not recommended, but if you're experiencing symptoms or have very low CD4+ cell counts, considering therapy might still be warranted.
Federal guidelines suggest considering therapy if your CD4+ count is also below 350. However, if your CD4+ cell count is high (above 350), it's reasonable to wait.
Viral load readings, especially in the first 3-5 years after infection with HIV, may be different in women and men. While viral load readings of 30,000-50,000 are generally considered moderate/low in men, this might be high for a woman and signal a more pressing need for intervention.
100,000 or Above (Considered High)
Increased risk of disease progression. Federal guidelines strongly suggest and encourage anti-HIV therapy.
For more information, read Project Inform's "Blood Work: A Useful Tool for Monitoring HIV;" WISE Words #3; and "Vaginal Candidiasis."
CD4+ Cell Counts
What is your current CD4+ cell count?
Over your last few tests, has your CD4+ cell count trend:
Is your CD4+ count generally declining or is it mostly stable, with just modest movement (100 points or less) up and down? A stable CD4+ count, as long as it is above 200, has less risk of progression than one that is steadily declining.
CD4+ Cell Count Above 500 (Normal Range 500-1,500+)
Maintain good healthy habits (nutrition, exercise, monitor disease progression and labs).
Therapy is generally not recommended. If your viral load is high and/or you're experiencing symptoms, therapy might still be warranted. However, if the CD4+ count is declining rapidly and consistently, and the viral load is high, some doctors might recommend treatment or more frequent monitoring.
CD4+ Cell Count 200-500
If you are in this range, you may want to consider therapy, especially if you have developed symptoms associated with immune dysfunction. Examples include shingles (zoster), and recurrent and aggressive yeast infections. When no symptoms are present, most doctors would consider delaying treatment at least until the CD4+ count consistently falls below 350.
Guidelines suggest considering therapy when CD4+ cell count is consistently at or below 350.
If your CD4+ cell counts are above 200, and you experience recurrent fungal infections (thrush, etc.), preventive therapy for Pneumocystis carinii pneumonia (PCP) is recommended.
CD4+ Cell Count 200 and Below
There is an increased risk for developing serious and life-threatening infections (opportunistic infections) and therefore the federal guidelines highly recommend anti-HIV therapy.
If you choose not to use antivirals at this point, talk with your provider about preventive therapies against common infections, like Mycobacterium avium complex (MAC), cytomegalovirus (CMV) and toxoplasmosis. Monitor your lab values, weight, minor symptoms and overall sense of well-being.
If your CD4+ cell count and/or viral load levels change drastically from one test to another, discuss this with your provider. Large sudden changes are often the result of lab errors or other health factors (like a flu shot or stress).
For more information, read Project Inform's "Blood Work: A Useful Tool for Monitoring HIV."
The Goal of HIV Treatment
Take time to understand how therapy works. Get informed so you have a solid foundation in understanding the goal of treatment. Learn about all of your possible treatment options. It's important to understand the risks and benefits of both starting and of waiting. If you start therapy now, what are the possible side effects and how will you monitor to make sure therapy is working for you? If you wait to start, or decide not to start at all, what is your risk of HIV disease progression?
Take time to talk with your doctor about his/her opinions and experiences with treatment and other people who you trust and have an understanding of therapy.
For more information, read Project Inform's "Anti-HIV Therapy Strategies."
What About Side Effects?
There are many side effects from anti-HIV therapy. It's important that you are aware of them and learn how they can be monitored and managed. Not everyone on therapy experiences side effects (only 10-20% of people have serious ones). It's not uncommon for people to have some short-term side effects like nausea and headaches during the first 4-6 weeks of therapy. After this adjustment period, short-term side effects often diminish. Therapies can have long-term side effects too, including body changes (called lipodystrophy) and changes in lab results like cholesterol.
For more information, read Project Inform's "Drug Side Effects;" "Lipodystrophy Syndrome(s);" and "Mitochondrial Toxicity and Lactic Acidosis."
|If you come to the decision that you want to start therapy, here are 4 other points to consider before starting and as you develop your strategy.|
Adherence is crucial to treatment being effective. Adherence means taking medications exactly as prescribed by your provider. If anti-HIV medications are not taken according to instructions, the risk of developing drug-resistant HIV increases. Drug-resistant HIV may not respond to the anti-HIV drugs and, as a result, treatment options become limited. Numerous factors can influence adherence: the responsibility of children, your housing status, busy and demanding work, potential side effects from anti-HIV drugs, being in a domestic violence situation and many others.
Take a moment to reflect upon the various factors that can make taking your medications correctly challenging. Discuss this with your provider as you develop a treatment strategy. In addition, use those sources of support which will motivate you to stay adherent.
For more information, read Project Inform's "Adherence: Keeping Up with Your Meds" and "Drug Dosing Schedule."
Have you been diagnosed with hepatitis C (HCV)?
Some anti-HIV therapies, especially protease inhibitors and non-nucleoside reverse transcriptase inhibitors, can increase liver enzymes and/or cause hepatitis. Liver enzyme levels should be carefully monitored soon after starting anti-HIV therapy.
Are you taking treatment for HCV?
A 1-2 month gap is suggested between starting HIV and HCV treatment.
Treating HIV or HCV first will depend on the stage of liver disease and your CD4+ cell count and/or (HIV) viral load.
Are you currently on any other therapy (contraceptives, methadone, anti-depressants, etc.)?
There are known drug interactions between a variety of drugs, and even herb-drug interactions. These can worsen side effects and/or cause one or both therapies to be less effective. For example, some protease inhibitors can decrease the level of ethinyl-estradiol (chemical in oral contraceptives), making them less effective.
If you decide to take therapy, take all the medications, vitamins, supplements and/or alternative therapies that you're taking to your next doctor's appointment. Whenever you add or change a therapy or supplement, be sure to talk with all your health practitioners (and pharmacist) to make sure these products may be taken together safely.
For more information, read Project Inform's "Drug Interactions."
Have you had any opportunistic infections (OIs) like MAC, PCP or CMV?
If you have an active OI, talk to your physician about treating that OI before you start anti-HIV therapy.
If you have had a major OI, aggressive anti-HIV therapy is almost always recommended after treating the OI.
Back to the Project Inform WISE Words December 2001 contents page.