Reba from NSW writes: I am a 45-year-old positive woman and I’ve been living with HIV for five years now without any problems. My CD4 count is currently 840 and my viral loadA measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. is about 10,000. I have been putting off even thinking about going on treatment but now with all the science showing that it’s a good idea (good for my health, protecting my partner, etc) I think I should start.
Dr Louise replies: This is a big issue, particularly at the moment, so thank you for your letter.
The debate about early treatment has been around for a long time and the pros and cons are still the focus of many discussions.
Your readiness to start antiretroviral therapy (ART) is a very important part of any discussion. You are the one with this disease and ultimately it falls on you to decide how and when you will treat it. Our job is to give you all the information on which to base those decisions.
You have obviously kept up with the science and probably heard that US guidelines have been recently updated to recommend treatment for everyone with HIV, regardless of CD4 count.
This is not yet the case in Australia. Currently, our guidelines recommend and our PBS[Pharmaceutical Benefits Scheme] The federal government program which subsidises medication costs in Australia. Anti-HIV drugs are part of a special part of the PBS called Section 100 (S100) which is used for expensive, highly specialised drugs. criteria specify that we commence therapy when someone’s CD4 count reaches or falls below 500. There are exceptions to this rule, such as having any HIV symptoms, being older or pregnant.
Initiating ART is usually a process of discussion between medical staff and you —with information about the potential benefits and risks of therapy being discussed, information given and then a few consultations to get the actual prescription right. We encourage our patients to think about the implications of commencing therapy and try to ensure that things are in place to maximise adherence and minimise the chance of any side-effects.
Occasionally there is limited time for decision-making (for example when someone presents late with an opportunistic infection and is very unwell) and then we usually want to start the meds very quickly.
But what about those of you with ‘robust’ CD4 counts?
We know that untreated HIV infection means there is constant replication of the virusA small infective organism which is incapable of reproducing outside a host cell. and over time this results in a decline of actual CD4 cell numbers and their function. Eventually this can increase the risk of many infections, cancers and inflammatory conditions.
It is clear that with people with a CD4 count less than 350 that ART is hugely beneficial, with a dramatic reduction in the progression to AIDS and symptomatic HIV infection.
Data also supports the commencement in the range of 350 to 500 CD4 cells with lower rates of progression to AIDS or death, and more often we are introducing the ARVs to our patients with these cell counts.
It is now postulated that commencing therapy at higher CD4 cell counts leads to lower rates of both HIV and non-HIV related illnesses and current studies are trying to evaluate this. START is one such international study and is currently enrollingThe act of signing up participants into a study. Generally this process involves evaluating a participant with respect to the eligibility criteria of the study and going through the informed consent process. in Australia.
HIV replication, even at high CD4 counts, still causes activation of the immune system and inflammation and this may increase the risk of non-HIV related diseases such as cardiovascular or renal disease and cancers. It may also play a role in the ageing process even at the cellular level, with dysfunction of immune cell function and death of immune cells.
Combination ART, like all medications, has the potential for short- and long-term side effects.
In general, current regimes are better tolerated and safer than earlier ones, but all still come with a list of potential side effects.
The long-term consequences of daily therapy with some of the newer classes of ART have not been fully evaluated. If treatment commences early, the added years on ART may contribute to cumulative toxicities over time.
On the other hand, when we commence the therapy in the setting of AIDS illnesses and opportunistic infections, there are often multiple other medications that can potentially interact with the ART and this can increase the complexity of the drug regimes and risks of side effects and interactions.
What about adherence?
The best chance of suppressing HIV happens when ART is taken consistently and this then influences clinicalPertaining to or founded on observation and treatment of participants, as distinguished from theoretical or basic science. outcomes and reduces the risk of drug resistanceHIV which has mutated and is less susceptible to the effects of one or more anti-HIV drugs is said to be resistant. developing. This is a very personal thing and for some people sticking to a routine of tablet taking is not difficult, especially if the regime chosen is simple and uncomplicated. But for others, depending on their work, psychological factors and the actual regime required, it can be quite difficult to reliably take the medications all the time.
Finally, what about reducing the risk of transmitting HIV to sexual partners?
Certainly there is evidence that rates of HIV transmission increase in the settings of very high viral load (such as around the time of recent infection) and in the presence of other STIs[Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). . Recent studies in heterosexual serodiscordant couples have shown that ART can reduce the risk of sexual transmission considerably.
So, risk-reduction is a consideration for starting. But it shouldn’t be your only motivation. Looking after your own health is number one.
I congratulate you, Reba, on considering all the factors around the ‘when to start’ question. I encourage you to consider what I’ve talked about and to start the conversation with your doctor.
Keep your questions under 100 words and email them to firstname.lastname@example.org
Dr Louise Owen’s advice is not meant to replace or refute that given by your own health practitioner, who is best placed to deal with your individual medical circumstances