Question
Are the benefits to early treatment including being less infectious?
20 May 2008. Related: All topics, HIV transmission, Starting treatment.
Hi. I have been diagnosed 14 months now and I am not on meds.
My doctor tells me my blood results indicate I do not need treatment yet, however, I have heard of people who decide to start them anyway as a means of staying healthy and being less infectious.
I was wondering if there are any merits to starting medication when there is no immediate need?
If I choose to go on meds against my doctors advice, do I have the right? Reading about the different types of medication, shouldn’t everyone be started as soon as thy are diagnosed in order to do as much as possible, as soon as possible, to stop the virus attacking the immune system?
The answers to these questions will help my understanding of the whys and wherefores of treatment.
Answer
Thanks for your questions which are important and interesting, and which need a complicated answer.
Generally, deciding when to start treatment is an individual decision that involves weighing the risks and the benefits at any time. In advanced HIV the decision is informed by hundreds of studies that show that once your CD4 count falls below 200 your risk of infections increases. This is why all guidelines recommend starting at 200 or before.
Guidelines are also moving to earlier treatment – either between 200-350 or before your CD4 count falls below 350. This move is due to two main developments i) recent studies showing a benefit of earlier treatment for reducing the risk of both HIV-related and non-HIV-related illnesses, and ii) that todays treatments are generally easier to take – with fewer pills, doses, and side effects.
Starting treatment even earlier, when CD4 counts are still above 500, is the subject of a large international study called START (Strategic Timing of AntiRetroviral Therapy) which is due to start in 2008. Some studies already indicate that being on treatment even at high CD4 counts can reduce the risk of some, generally rare, complications, and this study will help to clarify this.
Use on treatment very soon after infection is really only recommended in research trials. Most studies have not shown a long-term benefit from starting treatment in seroconverion unless you have symptoms or have progressed very quickly.
Risk of transmission is certainly related to viral load, and reducing viral load to very low levels when on treatment, is one factor that some people use to start earlier treatment, particularly if their partner is HIV-negative. At the moment there is a lot of debate about how low this risk goes, but it may prove to be one of the most effective ways to reduce transmission.
This is limited mainly by the high numbrs of undiagnosed people who do not know they are HIV-positive, and also because of cost, side-effects, risk of resistance and personal choice.
If you personally want to use treatment for this reason, then your doctor may be able to prescribe it, even though your CD4 count is higher than recommended in the guidelines. Some people who are very anxious about their HIV diagnosis use earlier treatment because they feel better keeping HIV controlled.
There is increasing evidence that most of the early damage form HIV occurs within the few weeks – far too early for most people to even have the choice for treatment to limit this. After those early weeks, HIV generally progresses very slowly, and it is difficult to pinpoint any specific difference between having a CD4 count of 600 or 800, making difficult to see any clinical benefit from really early treatment.
This report includes a discussion of some of these issues in the context of the proposed START trial.
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