Guidelines Prediction: Start Treatment Earlier

I decided to start meds when my CD4s were 503 because I am witch that can predict the future...

Given the vast improvements in meds, especially first and second line medications for HIV treatment (greatly reduced side effects, far more forgiving dosing, et al) I am in complete agreement with these guidelines.

As long as the person in question agrees to an open ended prescription with little to no variance, something that, using diabetes as a guideline, is remarkably hard to do long-term.

One must balance the point numerically about starting meds against the possibility of something like lipodystrophy. That's one of the primary, if not THE primary, reasons that most patients put off going on HIV medications. If this propensity towards mitochondria dysfunction did not exist certainly everyone would commence at 500 cd4 or so. It's quite simple to see that it is this concern that everyone fixates on -- just look at the AM forums.

I find it somewhat disingenuous not to mention this, if it was indeed not, at this Boston conference. However, I did not delve into the meeting minutes. There is certainly no mention of this in the poz.com treatment news write up.

I will add though that with the present or expected approval of the most recently developed ARVs (Prezista, Isentress, and Selzentry) as "first time treatment" options (as opposed to only being approved for those with large resistance profiles) is encouraging, as these three meds are notably less prone to side effects and I believe that tests have exhibited them having a low mitochondrial/metabolic toxicity.

In addition to what you're explaining here, these days it has been published one study showing the risks for the central nervous system when inmunological system reachs under 350 CD4 cell count. Authors are Jose A. Muñoz-Moreno et al, and the journal is AIDS Research and Human Retroviruses. Everyday, the importance of protecting inmunological system, and trying to start before, as well as maintain the treatment as long as possible, are shown to be more relevant in HIV infection. And surely this will be the future of current antiretroviral therapies!

It's hard for me to gauge the significance of this. A 71% higher death risk can mean different things depending on the underlying rate of death. If the rate of death for those starting when their counts drop below 350 is 2%, I'm not sure the cost of starting early exceeds the benefit of reducing the death rate from 2 to slightly more than 1 per cent.

And I wonder if cost should also be considered? Can the system (however it's funded) cope with everyone starting at 500?

Nobody mentioned that there are people that naturally have a low number of t cells.
We don't have to forget that adult healthy people have a t cell count between 500 and 1450 (that is a huge windows).
So what about if I am one of those people that before the infection has a t cell count of 500?
I should not be treated in the same way of who has a naturally higher number of t cells!!!

Probably my voice would sound out of the chorus but I like to keep in mind that a lot of studies on HIV are financially sponsored by pharmaceutical companies that, for obvious reasons, want people start the treatment as soon as possible!
I think we should balance all the news that come out and be as much critic as we can.
Personally when I tested positive I had 321 t cell and VL around 12000 copies. I did not want to star medication and I asked for an other count.
I got it and after 1 month my t cell were 549 and VL 32000...so no drug.
Got my last count after 3 months: t cell 429, VL 7000.
My numbers are not crazy? So again if t cells go up and down naturally in a such crazy way, is there something else we should consider before filling people with drugs?
I d love to have some feedbacks

I agreed with you.I stared meds back in 1990
with a t-cell count of 502.Never been sick a day. I truly belive it is because I did not waited.

Hi,
Here in India Government funded free ART is usually given only if the CD4 count is around 200.Starting by 500 is out of question here unless under very special circumstances. Pharma Companies influence in many study design and outcomes should not be belittled.
So be cautious.

I asked my doctor to start me on HIV meds last January when my t cells were at 700 (a 50% drop from 1400 over the prior year). I was also having major problems with fatigue that negatively influenced my quality of life. I told my doctor that even though I knew that my labs didn't meet official criteria for starting meds, I felt I was ready and would benefit, especially since research was coming out that showed starting meds with higher t cell counts improved overall quality of life, and newer meds have fewer side effects. It was about this time that the CDC revised treatment guidelines by raising the starting t cell counts from 200 to 350. Fortunately for me, I have a great doc who not only put me on meds that day, but told me "that's why they are called treatment GUIDELINES - they aren't strict rules that apply to everyone because everyone experiences HIV differently". Almost a year after starting meds, I'm undetectable, t cells are 950, and I feel so much better. In fact I now have the energy I needed to start a work-out/exercise program, which I would have been unable to sustain without meds. So starting meds early does make a difference and should be considered for more people. Why wait until your immune system is virtually destroyed before you try to bring it back with meds? The research shows that starting meds with a lower t cell count makes it harder for your t cells to recover. The current treatment guidelines are not absolutes and should not be used to deny meds to people who have t cell counts above 500. Starting earlier just makes more scientific/medical sense, and the studies will continue to support this. In fact I predict that in 2-3 years, they will be starting people on meds with t cell counts above 500. In the meantime I'm glad I made the choice to start meds when I did, and I'm confident that future research will validate my decision.

My t cell count is below 500, I feel really good and I have no intention to start medication. I have a PhD in pharmacology and i know for sure that every drugs, from aspirin to ART have side effects.
ART have a lot of side effects (lypodistrophy, hepatotoxicity, kidney problems, change in bone mineral density,psychiatric disorders..)
I know that these effects could not be experienced but I do not want to risk until I really need medications.
There are people that naturally have a very low number of t cell (barely 500) and they do not have HIV and they don't get sick.
There are also clinical cases of HIV positive people that have been living for 7-8 years with very low t cells count and without medications (and they are healthy)
The very first goal of Pharmaceutical Companies is to make money and they want us started taking medication immediately.
I think that 350 is the good limit.
Clinical data show that starting med at 350 is a successfull way to fight HIV (as a matter of fact people has been living a long life). So why to change the guidlines if they are working well? Why they want to intoxicate us with drugs before we really need them? The answer is: money.
I strongly believe that the psychological way in which we react to HIV strongly affect our immune system and our general health.
All these news about starting med early for living longer create generalized panic. Panic and being anxious affect our health much more than we can even imagine.

As a hospital infection preventionist, I wanted to point out another benefit of starting meds this article doesn't mention: decreased risk of transmission and drug resistance. It's a fact the people with HIV who are not on medications have higher viral loads and are more likely to spread HIV, no matter how good or healthy they feel. People with undetectable viral loads are far less likely to transmit HIV. Higher viral loads = more transmission. I don't buy all the conspiracy theories that treatment guidelines are being adjusted to help the pharmaceutical companies make money.

The fear of side effects is really more of a leftover from the 90's when HIV meds had higher toxic doses and more side effects. Current meds have lower doses and fewer to no side effects. I have no problems with side effects from taking truvada and intelence. In fact I'm actually healthier than I was before I started taking meds, and I've been able to make lifestyle changes that I was unable to sustain before taking meds. And if people do experience side effects from one med, a competent physician can help you try different combinations until you find one that works for you. A friend of mine started on Kaeltra and Truvada and had problems with diarrhea from the Kaletra. His doctor was able to switch him to another medication and he now has no problems.

The point of continuing to do research into the best time to start meds is to improve the quality of life and health of a larger group of people, not to make a profit for the pharmaceutical companies. Clinical research is ongoing, and treatment guidelines should and will be adjusted to reflect new clinical findings and evidence-based medicine. Past research supported changing from 200 t cells to 350, and current and future research will most likely show that starting meds when t cells are at 500 helps more people. It's not about enriching greedy pharmaceutical companies; it's about saving lives and improving quality of life for people with HIV.

People are free to accept or reject treatment as they see fit, and believe any wild conspiracy theories that they want, but you can't say the current treatment guideline of 350 t cells works well so why change. That is like saying "we have 20 meds for HIV, so why do we need to do any research for new meds?". Science and medicine are about progress, not status quo. The evidence will speak for itself.

I think that the only reasonable way of decrease risk of transmission is keeping to educate people to have safe sex.
Regarding drug resistance I totally disagree with you because has been shown that the HIV virus has been getting stronger.

When I talk about side effect I m talking about long terms effects like lypodystrophy.
Has been shown that change in body fat distribution can have detrimental effects on an affected person's self-confidence and quality of life, and can contribute significantly to depression.It can also significantly affect a person's "relationship" with his or her medications.
Lypodystrophy in not just something "aesthetic" but can also be an increase in blood triglycerides and cholesterol. That can increase the risk of a heart attack or stroke.
A lot of new meds still have those side effects

I know that science and medicine are about progress because I am a scientist too. What I meant is that if we look at the history of HIV treatment Doctors started been very aggressive and that they realized that was better to start when it really needed to be started. That has been working very well (since people is not longer dieing for HIV as in the past).
So what seems to me is that starting treating people when t cell count is just below 500 looks like to being again too aggressive.
When you chronically introduce in your body drugs like NRTIs, NNRTIs you dramatically change your body homeostasis because those drugs are not selective for Viral RT but they also inhibit Human RT an polymerase.
I do not mean that HIV has not to be treated. I believe that, until we are healthy (with a t cell number higher than 350), and we are responsible about safe sex, we should not take meds until we really need them. To balance between risk an benefit of an early treatment is what has to be done

I was diagnosed in Aug 2007 with a CD4 count of 800 and a viral load of over 500,000. It was caught within 5 weeks of transmission. I started meds immediately and my CD4 is now over 1200 and my viral load is undetectable. I think starting the meds early was the right decision in beginning the fight of this disease.

I disagree that the only reasonable way to decrease the risk of transmission is to teach safe sex. Obviously safe sex education, while important, is failing to prevent new infections. There were a few articles on this site about medications reducing transmission rates.

I read an article a few weeks ago that showed that HIV has not evolved to become any 'stronger' over the past 20 years of the epidemic. If I find the website again, I'll be happy to post the reference.

I think the newer meds won't have the degree of long term side effects that high doses of AZT and other PI's had. I think meds and HIV care have changed dramatically in the past 10 years, and with new meds with fewer side effects coming down the line, I think it's reasonable to say that the long term side effects will be less than what we saw with meds in the past.

It's a great time to be optimistic about longterm HIV care and possibly a cure.
Yes, doctors in the past used a 'hit hard, hit early' treatment plan, BUT they had more primitive meds and used higher toxic doses. The new approach to starting treatment earlier is different from the past goal of 'hit hard, hit early' since the newer meds have fewer to no side effects, and they are not at toxic doses that were associated with side effects.

Again the whole reason we're posting on this article is because of scientific research that presents hard evidence that starting meds with higher t cell counts benefits more people and prevents morbidity/mortality. The guidelines are guidelines, not laws set in stone. Not everyone will benefit from waiting until their t cells reach the magic number of 350 before starting treatment. "We're sorry Mr. Smith, your t cells are at 351, we can't start you on meds even though you feel horrible". Some people benefit from earlier treatment, including myself and others who posted on here. And I think the studies take into account the risk of side effects versus early treatment. And again they noted more benefit from beginning treatment at higher t cell levels. We'll just have to wait and see what results come from ongoing studies that are investigating starting treatment when t cells are at 500. The evidence will speak for itself.

Just as an addedum to my last post, here are the references for the studies into whether or not HIV is becoming more virulent:

http://polyscience.org/2005/09/less-virulent-hiv/
Research comparing samples of HIV-1 from 1986-89 to samples from 2002-03 have found the virus weakening. The new samples do not multiply as well and they appear more susceptible to drugs.

and

http://www.aidsmeds.com/articles/hiv_evolution_pathogenic_1667_15531.shtml
The researchers noted that the most dramatic decline in the number of CD4 cells occurred up until 2001, but has since stabilized. This suggests that HIV may have adapted into a more pathogenic virus earlier in the epidemic, but has not further evolved during the past several years.

5 years ago I was diagnosed positive as a result of a physical altercation and stabbing. Since I was still acute (just converting) the doctors thought it might be best to start treatment right away - that was pretty revolutionary thinking at that time. I ended up starting taking meds almost exactly 2 months after the incident. Because my immune system was still very strong I never had any side effects from the meds and to this day have remained undetectable with a CD4 count of about 55% and 1000 absolute (normal for anyone with or without HIV).

I forgot to mention in my previous comments that I was able to take the the first level HART regimine, Atripla, because analysis showed I did not have a drug resistant variety of the virus. All the studies I am aware of show this drug has very little if any toxic affects on my body. Also by starting very early I understand the virus probably never had much of a chance to get into the deep tissues of my body which may be important should there ever be a cure. As a 27 tear old I expect to live a full normal life.

Some things have changed though. I try to reduce stress by working out at the gym, take time to "smell the roses" of life every day and have moved from the City to the country where I feel more connected to nature and have a great support system from my neighbors (yes many know I have HIV).

I'm lucky in that I have been able to work and get medical coverage through my employer group plan.

“I think that one can mount arguments for not starting treatment earlier,” explains Daniel Kuritzkes, MD, a longtime AIDS researcher from Harvard Medical School in Boston. As an example, he says, “We don’t know if the benefit you might achieve in terms of reducing AIDS- and non-AIDS-related complications will be better or greater than the harm you might do from the long-term toxicity of therapy.”

from
http://www.aidsmeds.com/articles/hiv_early_treatment_2042_15656.shtml

Ultimately, Kuritzkes says, the best road may be a middle path between where we are now and simply starting everyone at 500. Such moderation will likely rest on the role that inflammation and over-activation of the immune system play in disease progression. Concerns about inflammation are part of the rationale for using ARV treatment earlier. Many experts believe that too much inflammation, which occurs when people are not on treatment and HIV is actively reproducing, may be a factor in many of the health complications seen in studies such as SMART and NA-ACCORD.

from
http://www.aidsmeds.com/articles/hiv_early_treatment_2042_15656.shtml

I think we can draw two conclusions from these recent articles on when to start meds and the comments posted. The first is that starting meds at between 300 and 500 T cells has been shown by these studies to reduce mortality/morbidity. I think we can all agree that raising the CD4 count from 200 to 300 was a good thing. The 2nd is there's valid concerns about toxicity from starting meds at higher CD4 counts because it means you take meds for a longer period of time. Both of these points will be evaluated in the current/new studies. So we'll have to wait until the results are in.

One personal observation... recently diagnosed people(within the past 5 years)who posted on here seem to be more open and accepting of starting meds. We also seem to report little to no side effects with our regimens, and we have experienced improved health/quality of life.

I wonder if there is a 'gap' between 'new' HIV'ers and 'old' HIV'ers when it comes to opinions about taking/starting meds?

In thailand they start meds at 200 cd4 count !! is this a bad thing? should one try to start earlier? feel OK just a cough that persists.getting confused about when to start.

I've poz for the past 7 years and im still not on meds. My viral load is steady at 6000 and my CD4s vary between 450 and 250.

I often wonder if this type of research is not indirectly funded by pharmaceutical companies. We all know they have little ethics when it comes to making profits, not matter what public relations or media campaigns they might orchestrate.

Of course its shocking to read that the death rate 71% higher in Poz people who have waited till their CD4s drop below a certain level before starting meds.

When are we going to see a true unbiased research on the matter?

Francis Charette
Ottawa