Hiv For The Newly Diagnosed

[cojones]

In the light of recent developments in the treatment of HIV infection, it is essential that any counselling following a positive diagnosis addresses the treatment options of the newly diagnosed person, whether or not they request such discussion.

Newly diagnosed people are likely to be offered the opportunity to discuss treatment options soon after diagnosis with a clinician. Practice will vary from one centre to another concerning the speed with which tests such as viral load and CD4 count will be conducted after diagnosis. However, this information has a crucial bearing on the discussions which a counsellor and clinician will have with a diagnosed person in the months immediately after a positive test result.

A number of scenarios can be envisaged, all based on examples given by clinicians or people with HIV.

Immediate treatment initiation

Some patients may be identified as likely to benefit from immediate initiation of antiretroviral treatment. This will depend in part on their state of health, and in part on the views of the doctor who conducts the test. For example, some doctors are keen to offer treatment to those who have been exposed to HIV very recently, or who are undergoing seroconversion.

In such circumstances it is essential that the patient understands the experimental nature of the intervention. Although treatment during primary infection has been shown to reduce viral load to undetectable levels in most patients studied so far, the numbers investigated have been small, and the drop–out rate due to inability to tolerate the treatment has been anywhere from 5% to 50% in all studies. In addition, approximately 5% of those who begin antiretroviral therapy at this stage are unable to comply with the dosing regimen.

It is also unclear how long the effects of the regimen will last. Adherence to the treatment regimen is a major determinant of a successful and lasting response to treatment. Patients need to understand the importance of adherence before embarking upon any antiretroviral combination.

Doctors are unlikely to encourage the very rapid initiation of therapy (within days) unless the patient is in the primary infection phase or has symptomatic disease.

Low CD4 count, high viral load

In such circumstances there is a high risk of disease progression and a likelihood that the outcome of therapy will be less beneficial if viral load continues to rise. This is because people with HIV appear to do best if their viral load falls to undetectable levels when they start treatment.

High viral load is no longer viewed as seriously as it once was in terms of making treatment decisions. Triple combinations using efavirenz or boosted protease inhibitors should be able to reduce high viral loads significantly. The higher someone's viral load the sooner they may need to start therapy, since higher viral loads usually mean that the CD4 count will decline more quickly. In the UK, it is recommended that treatment begins before the CD4 count falls below 200.

Triple combination therapy is standard in the UK as the first combination, but occasionally patients may be offered four drugs - particularly a combination of two protease inhibitors.

Low CD4 count, low viral load

If viral load is low (below 10,000 copies per ml), many doctors will take the view that treatment is not urgent. However, if the CD4 count has fallen below 200 – 250, they will recommend immediate initiation of PCP prophylaxis, since the risk of developing PCP is greater in people with CD4 counts below 200. At this point they will also recommend starting antiretroviral therapy.

If the CD4 count is very low (below 50), most doctors will urge that antiretroviral therapy should be commenced whether or not viral load is high, since the risk of developing AIDS–related symptoms is very high. Antiretroviral therapy may prevent further deterioration in the immune system.

Waiting until better treatments appear

It is important to be aware that dramatic improvements in the standard of HIV treatment are likely to continue in the next few years. Every month which goes by yields further information about how best to use the available drugs. This suggests that people who wait to begin treatment may enjoy better options in six months or a year, as long as they continue to monitor their viral load and CD4 count regularly.

This information should be drawn to the attention of newly diagnosed people as a reminder that they may not necessarily benefit from a rushed decision about starting treatment. There may be a strong desire to do something after learning one is infected, but this should be tempered by the knowledge that one's options will continue to improve providing that viral load is monitored and any danger signs acted upon.

Common treatment issues for the newly diagnosed

In the current climate of optimism about anti–HIV therapy, it is easy to forget that most people will find the decision to commence therapy just as difficult as the decision to take an HIV antibody test. Counsellors have a significant role to play in supporting newly diagnosed people in making decisions about treatment.

There is a growing consensus amongst experts in the field that the decision to begin treatment must include thorough consideration of the patient's treatment options if their first choice of therapy does not prove beneficial. For example, if an individual begins treatment with a regimen that contains a protease inhibitor, how will this affect their future treatment options?

Up-to-date information on the potential impact of treatment choices is available from a number of sources. Clients should be encouraged to spend time investigating their options, and should ideally have the opportunity to discuss what they have learnt with their doctor before making a decision.