Q: I am a 23-year-old man and I was just diagnosed in April with HIV after I went to my doctor for a painful rash. I had been diagnosed with shingles in March and then my doctor asked if I'd been HIV tested recently. I tested negative three years ago and have been mostly careful since then but I said yes and this time the test was positive. My T cells are 380 and my viral load is 62, 456 copies. My doctor sent me to a specialist who I like but who is recommending that I start on treatment. I have a couple of friends who have been HIV positive for a while and they aren't on any medication yet. Do I really need medications?
A: If you'd asked me this question two or three years ago I would have said that you don't yet need to be on medications. We know that the majority of people with HIV spend several years (ranging from two years to more than ten years) in a period that is clinically latent. That means that the T cell
count is not particularly depressed, the viral load is very steady and there are no symptoms of illness whatsoever. We know that the virus is still active during this time but there seems to be an equilibrium between the virus and the immune system and we've tended to hold off on treating patients until the T cells start to go lower, below 350. These days you may be aware that the recommendations for treatment suggest that we offer treatment to anyone with a T cell count under 500, even if they are asymptomatic. Studies have shown that patients do better overall if you don't wait until the T cells get lower.
For someone like you, what we'd call a recent seroconverter, there is the suggestion that early intervention can lower the viral set point. The idea is to reduce how much virus gets established in your system. One recent study of early treatment supported this idea. Because it sounds like you recently seroconverted (the shingles episode), it is not unreasonable for you to consider starting on therapy now, to protect your immune system. We don't have a lot of data to support this recommendation yet but it does seem to be the right thing to do.