When to start HIV medicines

The following section needs updated; however, nearly all of the content remains true today; I plan to update this section in the near future.

There’s no mystery about when to start HIV medicines.  Medical providers know exactly when you should start HIV medicines, just by looking at your medical information.  However, there is a bit more to it than that.  If you are not ready, willing, and able to start HIV medicines, all the good medicine in the world will not work.  Also, if your CD4 count is 2, you and your medical provider will have different thoughts and feelings about your beginning medicine than if your CD4 count is 350.  

Are you homeless?  Do you take street drugs or have a drinking problem?  Is your current living situation stable? Do you have major legal or financial problems?  Are you having major relationship difficulties?  Do you have a mental disorder that you are ignoring, like depression, attention deficit hyperactivity disorder, bipolar, or anxiety issues?  If you answer yes to any of these questions and if your CD4 count is more than 200, you may want to address these issues before starting medicines.  Once begun, you must take the HIV medicines faithfully for the rest of your life.   The problems listed above have a way of making it difficult to take the medicine without missing doses so it’s best to take care of these right now.  It may mean that you go to drug or alcohol rehab, see a psychiatrist, find a job, move in with a relative, serve your jail time, break up with an abusive partner, stop drinking, etc., so that these issues will not get in the way of your taking your medicines correctly.  I will write much more about this in the next chapter.  

Must Know

The goal of taking the HIV medicines is continued, daily suppression of the virus so that it is unable to multiply or cause much damage--a viral load of less than 50 is what you are aiming for.  Every day, every medical visit--an undetectable viral load.  One drug company has an ad that says “Detectable is unacceptable.”  That’s a great slogan to remember.  There is only one way to achieve and stay undetectable.  Take the medicines, as directed, every day without missing doses.  

The other goal of taking the HIV medicine is to repair the immune system.  Keeping HIV suppressed will allow your CD4 T-lymphoctes to be replaced and your immune system to be restored to a healthy level.     

The box at the end of this chapter contains the information your provider uses to figure out if you “medically” need to start HIV medicine.  I have placed the list in order of importance--Those conditions at the top of the list are more important than the conditions at the bottom of the list.

Nowadays, there are more HIV medicines to choose from, simpler medicine regimens (most “regimens” contain at least 3 HIV medicines), more effective medicines, and medicines with much less side effects.  I won’t say taking the HIV medications are a breeze, but compared to the choices we had more than ten years ago, these newer HIV medicine combinations are much better, overall. 

HIV can never be cured.  It can only be suppressed. Think of the medicines as giant hand slamming down on top of the millions of virus particles.  As soon as you let up the pressure on your hand and start raising your hand off the table (not taking your medicine), the virus becomes active again, your CD4 count will drop, and your viral load will go from undetectable to detectable.   

The virus will never be your friend, but your enemy.  However, like all enemies, you must have respect for this enemy and learn everything you can to triumph over this tiny organism that wants to take your life from you.

Reasons to start HIV medicine earlier rather than later include:

• Increasing research evidence that HIV causes problems with just about every organ system in the body--heart, blood vessels, nerves, liver, kidneys, skin, etc. 
• A weaker immune system makes it more likely that you may get cancer. 
• You are less likely to transmit the virus to others, if your viral load is undetectable.  However, if you are on medicines, but taking the medicines incorrectly and your virus is not undetectable, you may transmit “resistant” virus to others (see chapter on HIV resistance). 

Reasons to delay starting the HIV medicines include:

• The great effect taking the medicines will have on the rest of your life.
• The inconvenience of taking daily (or twice daily) medicines for the rest of your life.
• Side effects associated with the medicines--not as big a factor as in earlier years.
• Medical problems that arise from taking the medicines--allergic reactions, changes in your body fat, increased problem regulating blood sugar, cholesterol and triglyceride problems, peripheral neuropathy (foot and lower leg pain), etc. 
• HIV medicine “resistance” if you start the medicines and don’t take them correctly.  Development of resistant HIV means you will not have as many HIV medicine choices in your future.  
• Perhaps there are long-term effects of these medicines that scientists do not know about yet. 
• Because these HIV drug combinations (the “cocktails” have been used for only 13 years or so, we don’t yet know if they will continue to work for the next 10 to 20 years.
• Inability to commit to taking medicines for life.  This is a marriage, in every sense of the word.  You must first be attracted to, then fall in love, then commit to these tiny colorful objects for life.  There are some possibilities of a “separation”--side effects, allergies, etc., but you must recommit to another pill/partner immediately, work out your side effects/differences and continue your commitment for life.  “Divorce” is not an option. (There is one exception--see the chapter on pregnancy.  Yes, some pregnant ladies can get a “divorce” from the medicines after they give birth.)