On your marks…
*Nick, from Tweed Heads NSW, writes*: I have known that I have been HIV-positive for two years now (it could have been longer as I hadn’t tested for five years before that). I am writing because I have just been told I have a viral load of 50,000 copies and a T-cell count of 363. My doctor says I should think about starting antivirals but I am reluctant to do so — I have heard that the sooner you start treatments the greater chance your virus will develop resistance to the drugs. I also am worried about the side effects. One of the drugs I have been recommended to start on is efavirenz and a friend of mine had to take three weeks off work after he started that drug! I am in a full-time job with a lot of responsibility and I don’t want to have to live with these side effects before I really have to. Can you help me with the pros and cons of starting treatment in my situation?
Dr Nick replies: The ‘best time’ to start antiretroviral therapy is still unknown. All other things being equal, some doctors would recommend treatment in your situation, but many would not, particularly if their patient is reluctant to start treatment. The two main reasons that we give antivirals are to prevent progression to AIDS and to relieve the symptoms of HIV infection. If someone is unwell, they might start treatment despite having a higher CD4 count; however if someone is otherwise feeling very well, the choice is by no means clear. Many people do feel more well, better and more secure on treatment.
The development of resistance is a potential problem regardless of when you start therapy. It is related to adherence (not missing doses). Whenever you decide to start, it is critical that you have planned for this, and not just left it to chance.
Clinical trials have proven beyond doubt that people with CD4 counts lower than 200 benefit significantly from starting treatment. However, it is not clear if those that start treatment with a higher CD4 count are better off than those who wait until the CD4 drops closer to 200. Those in the grey area above CD4 can either opt for treatment or for close CD4 and viral load monitoring.
As to drug choice, if you have never taken treatment before you have a wide range of options available to you. Efavirenz is a very good antiviral drug, commonly used in the first combination. Most people do not notice side effects as severe as your friend, although like any antiviral this one is not for everyone. My experience is that many people do notice side effects initially, though they don’t have to take time off work, and that most of those side effects subside over time.
People starting medication for the first time, called treatment naïve in medical terminology, have many choices. As long as adherence is good, then response rates are very high. It will be possible for you to find a combination that is simple and easy to take and has few and no side effects. To that end, I think it would be useful that you consider all available options, if you have the time and energy to do so. Your local treatments officer, AIDS Council and your doctor are useful sources of information.
My friend won’t listen!
*Jill, from Clayton Vic, writes*: I have a friend who has only 60 T-cells and she won’t take antivirals. She believes in alternative therapies such as naturopathic medicine, acupuncture and regular exercise. She says she will take the drugs when she absolutely has to but from what I can find out (I am not positive myself) she should be taking them as soon as her T-cells go below 200. She will not tell me what her viral load results are so I can’t tell you that. I am very worried for her but she has been like this for over two years so I’m not sure whether I should be as worried as I am. She has not had any illnesses and she has had HIV for more than ten years.
Dr Nick replies: Many positive people use complementary and natural therapies. I am convinced that they help many to achieve a sense of good health and wellbeing. However, for those with a low CD4 count, I am similarly convinced that they are not strong enough to prevent the progression to AIDS.
I think you have good reason to be worried for your friend’s health. She has been fortunate so far. However, history and experience tell us that AIDS progression will occur at some point. Medical research has shown repeatedly that health, quality of life and longevity are all greatly improved for people in your friend’s situation if they commence treatment.
I cannot speak for your friend, but many people are understandably fearful of medication. There is no doubt that some have bad experiences, particularly those who have accessed treatment for many years and in whom the virus has developed resistance, requiring the use of complex drug combinations. However, on the other hand, those starting for the first time, even with a low CD4 count, have a wide range of choices and are very likely to find a simple combination with few or no side effects.
Warts and all
*Barry, from Preston East Vic, writes*: I have a recurring problem with anal warts: I have had them removed surgically three times. I am not having any anal sex and certainly not any unprotected sex these days so I’m not sure why they keep coming back. Is it because of my lowered immune system? I have had around 200 T-cells for the past six years. They never go up or down much but I have had undetectable viral load most of the time. I am on Kaletra, abacavir and tenofovir. I have heard that there is a new cream called cidofovir which has been tried successfully in the US. Do you know anything about this and is it likely to come to Australia soon? I would not like to have to undergo surgery yet again.
Dr Nick replies: Recurrent anal warts are a very tedious problem, and the surgery is downright traumatic! Unfortunately, surgery and other less invasive treatments like freezing remove the wart but not the virus which causes the wart, the human papilloma virus (HPV). Currently, only the body’s immune system can get rid of HPV infection. The lower the CD4 count the more difficulty the immune system has eradicating the virus, which lives in the top layers of the skin almost out of reach of the immune system. There is a cream, called imiquimod, which stimulates the immune system to attack the wart virus which is widely available in Australia but is fairly expensive. Because it harnesses immunity, the weaker the individual’s immune system the less well it works, but it is still cheaper than surgery, and might be worth a trial for you.
Cidofovir has been trialled for the treatment of HPV infection with response rates of about 50 percent, which is actually not too bad for a notoriously difficult-to-treat infection. To my knowledge, cidofovir is not available as a cream in Australia, but the drug is available for other purposes and I gather it is possible to make it into a cream. However, it is very expensive indeed and getting access is likely to be difficult. Good luck!
