Should I start treatment in seroconversion?
I am 49 years old gay man and have just been diagnosed – right in the middle of my sero converstion – 2 weeks after catching the virus.
My blood test has revealed a vey high virus load (2 million) – and a more normal CD4 cell level (400).
My HIV doctor at the offered the option to start the medication now – based on a recent study. He said that it would mean getting the medication for the rest of my life.
My initial reaction was to wait as the blood test was done in the middle of the seroconversion at a time when my body was reacting strongly to the virus, and I was hoping to see the levels coming down and stabilising soon.
I need some advice on the option to start the treatment now vs waiting. Has the treatment needs to be for life – or is there an option to have the medication for a period (6 months – 1 year) , to help the system to stabilise? and then wait hopefully a few years for the levels to come to where I need to start a lifetime medication?
Thanks for your advice.
Your situation is very specific because of how early you have been diagnosed.
Treatment guidelines in 2016 now recommend treatment for all HIV postive people. This includes people in very early HIV infection.
Early infection is diagnosed as being within six months of infection. Within this six month window, the earlier you start treatment, the greater the chance of additional benefits.
Seroconversion usually starts 10 to 14 days after infection, so you are very early in this window. Treating this early might have benefits much later in terms of long-term hopes to cure HIV. This is still speculative, but it is important you have informtion to help your decision.
Some researchers think that by starting treatment early in infection, you may get a lower amount of resting HIV in sleeping cells in your body. These are sometimes called a reservoir of latently infected CD4 cells. Todays drugs cannot work against HIV in these cells. Ongoing research is looking at how to target this cellular reservoir, and plausibly, people who have a smaller reservoir, might be able to be cured more easily in the future.
This study from 2014 reports on how early treatment reduces the reservoir of infected cells.
There are no promises with early treatment, just the potential that this might help in the future. As you are the person taking treatment, you need to decide whether this is something you are interested in.
Two other aspects of this research are interesting.
One is the case of a person in the USA who started treatment in very early infection, He continued treatment for over 10 years with an undetectable viral load. After 10 years, scientists (led by Tae-Wook Chun) needed to looked through nearly two billion CD4 cells to find active HIV. This person decided to stop treatment, and his viral load still rebounded (about 50 days later).
The second is a group of about 32 French patients (called the Visconti cohort) who started early treatment. When this group stopped treatment after 3 or more years, ten of them were able to keep viral load controlled without treatment for about 6 years (range 4-10 years).
See this report about cure research from HTB:
and this summary of 14 people in the Visconti study:
Many treatment interruption studies showed that when people stop treatment, even after many years, viral load usually rebound quickly. This is because of the viral reservoir. But many other groups reported that some people, likely to be a tiny minority, are lucky enough to generate immune control.
This is a UK case report of someone who managed to stay off-ART for more than 10 years:
You are lucky enough to have a doctor that is giving you this choice. This is becasue even with new gudielines soem doctors hold back this option.
Another practical advantage from early ART is that you will be much less infectious to your sexual partners.
If you find treatment too difficult, or you change you mind in the future, you could always stop treatment knowing you have given this a go. Although treatment breaks are not generally recommended, there is no need to get stressed about thinking the decision you make now is for the rest of your life. If it doesn’t work out, the actually risk from taking a break is very low – though you might go through similar symptoms to your initial infection again. Also, optimistically, the hope for cure research is that many of us may eventually be able to stop treatment at some point in the future. This is likely to be at least 10-20 years away.
Although your viral load is high compared to people in chronic infection or on treatment, it is common for viral load during seroconversion to be several million copies/mL. You will be very infectious to sexual partners while it remains this high.
Several studies have treated people in early infection and not seen clinical benefits or even CD4 benefits if it is stopped after a few months or even a year. The Spartac study in the UK treated people for 3 months or a year and saw no differences compared to people who did not use early treatment. Spartac showed there is little benefit for just using treatment for a year.
This answer was updated in January 2016 from a question posted on 19 March 2012.