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2nd about t. Strategies (smart)

Feb 17, 2002

Thank you for your previous answer. It may be as you say: a good strategy for those people whom are currently in that number of cd4.

But one thing I dont understand very well, and allow me to say so, is that aim for not treating people until cd4 drop to 350 as current guidelines suggest. My experience as a positive women, having been on meds since they came out with nearly one year interruption when I had 840 cd4 until they dropped to 475 (lowest ever in 17 years), is that maintaining fairly high cd4 is nearly your best bet; you seem to suffer less physical changes when treatment and you are better prepared to overcome the ones you have experienced if you change treatment, and clearly you play on safer ground when treatment interruptions because there is always that margin of cd4 that you have never lost before and which keep you in fairly good shape.

Sorry if this does not go with the current, but it could also be a good treatment strategy, dont you think?

Thank you

Response from Dr. Cohen

No doubt that there are several attractive, compelling arguments in favor of starting meds with a high CD4 count and keeping them there. No doubt that the higher the count, the more likely it is that our immune system can safely do all it is designed to accomplish. Indeed, that is why maintaining the control of HIV from now on is one of the two arms in the SMART trial - since there are many good reasons to do so, and lotsa meds to accomplish this. And the hope for this arm of the study is to suppress HIV and stay one step ahead of the side effects by doing what can be done to change and switch and avoid med toxicities if at all possible.

There is no quarrel with that part. The only reason the trial exists however, is that there are downsides to these meds for at least some who take them. And these side effects clearly get in the way of the good stuff they do. And side effects can lead to erratic dosing as a way to minimize these problems. And the erratic dosing is one reason why we also see resistance to these meds. And so the idea in this study is to compare the strategy you describe - and keep half of the people treating HIV in the best ways we now know how - keep it controlled - versus another way using intermittent therapy. Avoiding the meds allows people to avoid med toxicity.

So we designed this study noting that both arms have a pro and a con. And that's where the study comes in - to see which works out better - rather than just guess. You may be right - the treat-at-high-counts-and-don't-stop arm may win for some of the reasons you mention - the other arm may note more illnesses in time. But the "treat-always" arm may report more med side effects... and so we shall see.

I've included a link to it below for readers who wish to read more about this.

The link to this study

Change first successful regime after 5 years.
adding in tenefovir

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