Question

When should I start treatment and which combinations should I take?

19 April 2010. Related: All topics, CD4 and viral load, Side effects, Starting treatment.

Hi,

I was infected and diagnosed within the last six months. My recent test results are CD4:490, CD4%:30 and viral load:55,000. I am 53 and apart from HIV have no other health issues.

Over the last few months I have been doing a lot of reading about HIV, particularly about when to start treatment.

I have been particularly interested in the views of Dr Joel E. Gallant, Professor of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine. Dr Gallant adopts an ‘opt out’ view on treatment on the grounds that untreated HIV places the immune system under constant pressure leading to uncontrolled inflammation throughout the body. He also advocates early treatment in older patients due to the slow recovery of CD4 cells even under treatment. I have discussed this with my consultant and he has agreed to start me on treatment as soon as I say so.

The treatment options I am looking at are:
Atripla
Truvada + Prezista/Norvir
Truvada + Reyataz/Norvir
Truvada + Isentress

I would greatly appreciate your views on;
1. How much of an expert is Dr Gallant on HIV treatment?
2. Whether you agree with Dr Gallant’s justification for early treatment?
3. Is CD4 cell recovery significantly less in older patients even on treatment?
4. Of the four combinations listed what are the pro’s and cons in relation to duration and severity of any side effects, the toxicity of each treatment regime in relation to the long term adverse affects on the body and finally how dependant is each combination on strict adherence?

Sorry this is a bit long winded but your views would greatly help me in deciding when treatment should start.

Thank you.

Answer

Answer: Charlotte Walker

Thank you for your questions.

I will try and answer your questions using the numbers you have given above.

1. Dr Gallant is indeed an expert in the field of HIV in the USA.

2. Dr Gallant’s ‘opt out’ strategies are related to testing rather than treatment. He promotes a model whereby the healthcare worker rather than the patient initiates the HIV test. The patient is informed the patient and given the option of ‘opting out’ of taking the test. This way HIV testing would be routine for everyone accessing care rather than waiting until people are showing symptoms. This would mean that more HIV positive people are diagnosed earlier in the infection and then have the option of starting treatment whilst their immune system is still strong. In the USA the ‘opt out’ approach has shown an increase in the number of people testing for HIV.

The decision about when to start treatment is a hot topic at the moment. Current UK guidelines suggest starting when the CD4 count is 350. However, in the USA the guidelines have recently changed to starting treatment at a CD4 count of 500. Interestingly, most doctors say they would start HIV treatment as soon as they were diagnosed for the very reasons you say. If you start treatment whilst your immune system is still strong then it never has chance to deteriorate. The time you are not on treatment your immune system is constantly working to fight off the virus. It is this immune response which causes inflammation and may be resulting in problems as you get older. This is only becoming apparent now that good treatments are available and people are living longer with HIV.

There is a new trial called START which is due to begin very soon and will look at whether it is better to start treatment at higher CD4 counts. For more information on this please follow this link.

3. CD4 cell recovery has been found to be less in older patients who have started treatment. Disease progression is also faster in older people.

Older people are usually excluded from clinical trials so there are fewer studies about CD4 cell recovery in older people. However, now more people are living longer with HIV, HIV and aging is becoming a popular area of new research. In the majority of these studies the term ‘older’ refers to people 50 years of age and above.

One study found that people aged 50 and over had a slower CD4 cell recovery than younger people. Therefore the time for CD4 cell recovery to above 500 was longer. This study also found that older people had a better rate of viral suppression which means they were able to reach an undetectable viral load more quickly. This was put down to improved adherence to medication amongst the older participants.

The reason for this is thought to be that people over 50 tend to have a less active thymus glad. The thymus gland is where the T cells are produced. This could explain why the CD4 count in people 50 and over is sometimes lower.

4. When deciding which HIV treatment to start it is important to remember that HIV treatments are very individual. Everyone has a different experience with side effects after taking HIV treatment. Most people experience only mild to moderate symptoms. It is impossible to say how you personally will react to the drugs. There are treatments available for side effects to make them easier to manage.  You should find that after 2-4 weeks your body begins to adjust to the medication and the side effects lessen. If after this time the side effects are still bad you should speak to your doctor.

Please follow this link to the i-base guide to ‘Avoiding and Managing Side Effects’ and this link to the ‘Introduction to Combination Therapy’ guide

To give you a more specific answer about each of the drugs you have mentioned would be difficult in this space. However, there are websites which give good detailed and easy to understand descriptions of each drug, the possible side effects, drug interactions and how to take them etc. To find this information please follow this link.

All treatment is effective it depends how well you respond to it. Atripla – the only three in one pill, easy to take, once a day but again it depends on whether you get side effects or not.

For any further information please contact us again via the website or call the treatment information helpline (Mon-Wed 12-4pm).