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Starting Med at 350? 250? 200?
Jan 18, 2008

What is the difference in starting meds at 350cd, 250cd, 200cd?

I know of people who had 17cd when they first started treatment and they are fine now (Their cd4 count is good and they look physically healthy).

Why the rush to start at 350 now? (Pressure from the pharmaceutical companies to make more $$$?)

Response from Dr. Frascino

Hi,

Hypothetically the optimal time to begin treatment of any infection would be as soon as the diagnosis is made! So why doesn't this apply to HIV/AIDS? Good question. Glad you asked. It would apply to HIV/AIDS if we had a cure or if we had safe, effective drugs that could be used for very extended periods of time. Unfortunately we have neither. At least not so far. As with any medication, we must balance the potential benefits against the potential risks. Yes, we all know lucky individuals who had extremely low CD4 counts who responded dramatically to potent antiretroviral medications. Unfortunately, this is not always the case. The individual with an absolute CD4 of 17 was at significant risk for developing an AIDS-related complication, such as an opportunistic infection or malignancy. Many of those opportunistic illnesses are not curable and can be fatal. So just as there are folks who smoke cigarettes well into their 80s without apparent significant harmful effect, there are far more who develop lung cancer, emphysema, heart attacks or strokes. In other words, you can't assume everyone will be as lucky as that 17-CD4-cell-count guy. In fact, the majority of folks will not! Also immune reconstitution is a complex phenomenon. Even though someone's CD4 count may improve significantly, that doesn't mean he is as immunologically intact as someone who never dropped his CD4 count to such low levels.

The history of guidelines advising when to start HIV meds has been convoluted, to say the least, and reflects our ever evolving understanding of HIV pathogenesis, immune reconstitution and the potential side effects and toxicities of anti-HIV medications. When potent HIV drugs first became available, the treatment mantra was "Hit early. Hit hard." Therapy was recommended for HIVers with CD4 counts of 500. As we learned more about the unanticipated short- and long-term side effects and toxicities associated with the available HIV drugs, treatment guidelines became more conservative not recommending commencement of therapy until CD4 cells dropped into the 200-250 range. Now that we have learned more about immune reconstitution and have less toxic, more convenient HIV medications available, the guidelines are once again changing. Currently most guidelines recommend treatment be started at 350 or below. Does this reflect pressure from the pharmaceutical companies? No. The guidelines reflect our current understanding of what will decrease HIV/AIDS morbidity and mortality. There is a wealth of information about this and related topics on this and other reputable HIV information Web sites. I'd recommend you peruse these resources and discuss treatment options with your HIV specialist. Guidelines or no guidelines, there is no one correct answer as to when is the optimal time to begin treatment. As far as HIV treatment is concerned, the mantra now is "One Size Fits One!" Therefore what might be best for you or the 17-CD4 guy might not be best for the next guy. Personally I do agree with the current trend in the guidelines to recommend treatment at higher CD4 counts.

Dr. Bob


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