My HIV viral load is at 34K and holding. I have recently tested positive for two types of parasites. My doctor says I am in great health, but I am concerned about my viral load being high. My doctor is still not recommending any HIV medications. I feel fine but am a little worried about all of this. Please tell me what is happening to me, and what you recommend.

A.D.

If left untreated, AIDS, an advanced stage of HIV infection, and die of infections or other conditions related to their disease. Before the availability of newer treatment regimens (drug combinations generally known as highly active anti-retroviral therapy, or HAART), the only thing we could do for patients with AIDS was to try to prevent some of the life-threatening infections that are likely to occur. In the era of HAART, we can now delay the onset of AIDS and increase short-term survival. Since these drugs have not been available for long, no one can know the long-term efficacy of these treatments.

Several groups have published recommendations regarding the treatment of HIV infection in adults. Although these provide guidelines for therapy, one can never say that any specific patient should or should not be treated with medications. A physician must take into account several factors when considering treatment for a patient with HIV infection. Probably most important is the patient's state of mind. Before a person begins taking the medications to treat HIV, he or she must realize that it is a major commitment. HAART involves taking multiple doses per day of at least three drugs, and all doses should be taken without fail. Evidence suggests that missing only a few doses can decrease the drugs' effectiveness. Other considerations include the many possible side effects of each of the drugs, not to mention their cost. Before any patient is considered for therapy, the doctor must have some confidence that the patient will be able to handle it.

Another factor important in deciding whether to begin therapy is the stage of HIV infection. HAART has been shown to have clinical benefit in those with advanced HIV disease and immunosuppression (impaired disease-fighting capacity). HAART has many theoretical benefits in those with asymptomatic HIV infection, but it has not been demonstrated in studies to have long-term clinical benefit.

In general, HAART should be offered to patients with symptoms or signs of disease, those with higher viral loads (usually defined as more than 10,000) and those with some degree of immunosuppression (usually defined as a T cell count of less than 500). The viral load is the amount of virus in the blood, and the higher the level, the faster HIV progresses. The T cell count tells us how advanced the immune suppression is at any given time. Since your viral load is 34,000, most experts would begin therapy, even though your viral load is "holding." The viral load typically reaches a "set point" and remains fairly constant until the last stages of HIV. That means that you could develop significant immune suppression without much change in your viral load.