| To Treat or Not to Treat?
Deciding When to Start Antiviral Therapy
Deciding when to start antiviral medication is one of the most
confusing HIV treatment decisions there is. Obviously, monitoring
your immune system with CD4 cell tests and viral load counts is
important so that you can get some idea of when your body might
need chemical reinforcement against the virus. If you have symptoms
of AIDS or advanced HIV illness, most Western doctors agree you
should take anti-HIV drugs. If you have 350 T-cells or less, most
guidelines recommend that you consider anti-HIV drugs. Even these
guidelines are regularly reexamined and updated, in light of new
information and new drugs available to fight HIV. The federal government
posts their recommendations at www.aidsinfo.nih.gov
and GMHC's Treatment Education Adherence Program has regular forums
to help you understand some of the issues (see our
Calendar of Events).
In general, most guidelines recommend that treatment should be
offered if you are asymptomatic and your T-cell count is less than
350 or your viral load is 55,000 PCR, 30,000 bDNA. If you have symptoms
(AIDS, thrush, unexplained fever), guidelines recommend treatment.
If you are having symptoms of new HIV infection, many doctors also
recommend immediate treatment through a clinical trial.
| |
Tcell |
VL |
Treatment |
| asymptomatic |
above 350 |
below 55,000 PCR
30,000 BDNA |
treatment not recommended |
| asymptomatic |
below 350 |
above 55,000 PCR
30,000 BDNA |
treatment recommended |
| symptomatic* |
any |
any |
treatment recommended |
| acute infection |
any |
any |
treatment recommended through a clinical
trial. |
* Symptomatic includes anything from thrush, shingles, or oral
hairy leukoplakia to PCP, CMV, or MAC.
If, however, you have a low amount of HIV in your blood, no symptoms,
and a CD4 cell count of more than 350, the benefits of early treatment
are less proven. Most experts would wait and monitor your immune
system. Though we know that medications can reduce viral load, we
don't know how long that reduction will last. Many people with AIDS,
and people who treat them, wrestle with the question of how early
to start, and whether starting medications early might mean wasting
an opportunity to get the benefits later.
Complicating the decision is the fact that, in most doctors' minds,
HIV treatment is forever: a lifelong commitment to taking medications
which have side effects, are expensive, and require complicated
changes in diet or daily routine. If your body doesn't tolerate
the drugs, or you can't manage to do what you need to do in order
to use them correctly, starting treatment can do more harm than
good. Missing doses can allow HIV to become resistant to drugs,
meaning that what you do today could limit future options tomorrow.
Some people find that the anti-HIV drugs make them feel sick, when
they'd previously always felt fine. On the other hand, you may lower
your viral load substantially if you put up with a few side effects,
and some doctors think that the earlier you start, the better chance
you have of staying healthy.
While some doctors may push you to get treatment as soon as possible,
they may not know the situation in your life as well as you do.
If you haven't told your live-in partner you're positive, for example,
is it realistic to start a medication that you have to keep in the
refrigerator at home? If you don't have health insurance, might
you be able to connect with ADAP, the AIDS Drug Assistance Program,
to help you pay for your medications?
Unless you're experiencing symptoms of primary infection (flu-like
symptoms, also known as seroconversion syndrome), HIV has probably
been in your body for a while. Taking the time to make the right
treatment decision is going to be helpful, rather than harmful,
in the long run. On the other hand, if you've recently been infected,
there is some evidence that starting immediately may be beneficial.
Finally, many people with HIV — including those on medications
and those who feel they can afford to wait — have found nutrition,
acupuncture, and stress reduction useful as complementary approaches.
If you are experiencing side effects from medication, definitely
check out ways to minimize them so that you can keep up regular
dosing, and keep levels of HIV down.
Howard Grossman, MD, an AIDS specialist, suggests the following
questions as a way of assessing whether you're ready to start treatment:
- What are the chances of your suffering significant disease progression
in the next couple of years, based on your CD4 and viral load
numbers over the preceding few lab tests? (One reading is not
enough on which to base treatment recommendations; at least two,
possibly three, should be analyzed.)
- Can you commit to taking medications every day - at least twice
a day - for the foreseeable future and not miss doses?
- How will medications affect your work and home schedules?
- Has your doctor discussed all the possible side effects and
what to do if they occur? Are you willing to endure those side
effects until possible remedies can be found?
- Has your doctor discussed what the next step would be if you
find you cannot tolerate the medications?
- Can you be open and truthful with your doctor about your medication-taking
habits, missed doses, recreational drug use, etc.? (If not, perhaps
you need to find a new doctor.)
What can you do to decide?
Learn all you can, stay up to date, and find
a doctor you trust. Since a lot of medical information is complicated,
you might want to check out GMHC's HIV/AIDS
Glossary for help with the technical terms. Choosing
a combination that will work for you may be as important as
the decision to begin treatment in the first place, so it's best
to get informed before taking a drug. Our Links
page contains numerous sources of information. Project
Inform, aidsinfonet.org
and AIDSmeds.com
are other good Web sites.
© 2006 Gay Men's Health Crisis |
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