Hi Dr. Young,
I received my viral stats today: with a viral load of 82,400 and a CD4 level of 297. I'm newly diagnosed and no HIV expert...but even I know these numbers are very bad, especially with the sky high viral load. However, the doctor still recommends that I first finish treating the PCP before I start on the ARTs, I've only been taking PCP for 4 days...so that means I would need to wait over 2 weeks! Should I take the ART early against my doctors wishes? What is the thinking behind this?
The doctor prescribed me 4 months worth of HIV meds for my trip back to Shanghai, consisting of Edurant Tablet (25mg), Ricovir-EM (Tenofovir 300mg/Emtricitabine 200mg). The doctor said I'd need to be back for another visit to see if the meds are working in 3 months time (tentatively scheduled meeting with doctor is March 26, 2015) is this normal or seem delayed? The doctor said it takes a full 3 months to know if the meds are working. With 4 months worth of meds I would have enough to start taking the ARTs now.
One thing I'm worried about is my HIV-strain test is not out yet, will take another week. It would be a nightmare to have a mutated strain of HIV. All these meds I bought will be useless right? I talked though this with my doctor, but I didn't seem to have any other option than to buy 4 months worth before knowing for sure or risk being in Shanghai without any ARTs.
Really appreciated your advice and expertise. Thank you very much.
Hello and good to hear back from you.
First, your CD4 count isn't actually that low (AIDS is usually defined by a CD4 count below 200) and viral load isn't that high (usually defined as greater than 100,000).
Second, your doctor's opinion about when to start ART is a bit dated, though was standard a few years ago. The May 2014
US Department of Health and Human Services recommendations state, "several conditions increased urgency for therapy, including acute opportunistic infections. In the setting of some opportunistic infections, such as Pneumocystis pneumonia early initiation of ART, is associated with increased survival, therefore, THERAPY SHOULD NOT BE DELAYED." (My emphasis.) This recommendation has an AI rating- meaning the recommendation is strong and the quality of evidence comes from one or more randomized trials with clinical outcomes with validated laboratory and points supports the recommendation. This is the highest rating of any evidence-based guidelines.
Regarding follow up, here in the US, I'll typically see a patient back in clinic about 1 month after starting meds, to check on tolerability/toxicity/adherence and check an initial viral load response. While not mandatory, it signifies a desire to make sure that things are tracking appropriately.
Having a resistance test is recommended- and waiting for the results is acceptable, as you wouldn't want to start a medication that your virus is already resistant to. That said, resistance to the three meds you've been prescribed would be relatively uncommon.
Your viral load should be approaching undetectable levels within 3 months of treatment, and this is, therefore, a reasonable time interval to have a face-to-face with the doctors in Thailand.
Hope that helps,