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When should we start medication?
Jan 1, 2009

Dear Doctor Moyle, My good friend was diagnosed HIV + on the 24th of November 2008, and so I have become his confidante and with him on my mind I have become rather inquiring about the disease. His CD4 reading at the moment is 474, he is 24 years old, ok lifestyle, does not smoke, drinks occasionally and that's about it. Once he was diagnosed, we were told he had to visit a government hospital (this is Malaysia by the way) and from my readings from here, I expected him to be given some form of medication and I think we were all flabbergasted when he was told that the hospital would only give him some form of medication when his CD4 falls to 200 and below. How can this be? How do they expect him to build up his CD4 level without any help? The counsellor told him that his CD4 will only go down and can never be boosted up again, and with all the readings I have been doing I find this totally wrong. I don't want to see anything happening to my friend, its just not fair. Malaysian Government hospitals are more worried about the cost then actually repairing the person, how can he get these drugs because private hospitals in Malaysia do not have anything to do with HIV related people. I need to know if starting him on medication when his cd4 level is 200 and below is too late or not? I believe it is. Nicholas Pillai

Response from Dr. Moyle

While I cannot comment on specific national care policies, but as you recognise some of the advice your friend was given is plain wriong. I am glad you have access resources like to learn the correct information. Most western countries recognise a starting CD4 level of <350 as a starting point with some further considerations for starting earlier. As Malasia is a former UK colony (:-)) I refer to our UK guidelines ( which have a couple of easy to read tables sumarrising starting issues. The UK is a cost sensitive market but is aware of the cost-benefit of starting at the CD4 350 level. So you friend does not need treatment at his current counts but should be monitored every 4 months for CD4 decline, meanwhile you and he can advocate and negotiate with his physician about when to start in line with international guidelines. I wish you and him the best of luck Kind regards Dr Moyle

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