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the right time for sure?
Nov 1, 2002

regarding when to start treatment: i know the general rule is once the t's r down below 200, time to intiate therapy because chances of developing opportunistic infections grows. but have there been recorded cases where someone who refused to take his meds was walking around looking and feeling healthy, but below 200 t's and shortly after DID develop o.i.'s? could it be that the t cells are bound to sometimes dip below 200, but that without using meds, they will most likely rise again just like they fluctuate normally?

Response from Dr. Wohl

Hi-

This is an important question. The whole idea behind recommendations to start HIV therapy when the T cell count hits 350 (US guidelines) or 200 (British) reflects several studies that looked at large groups of HIV positive people who initiated HIV therapy at various points in their illnesses.

The bottom line of these studies was that when people started therapy BELOW a T cell count in the neighborhood of around 200-350 the odds of their being on our green Earth was remarkably lower than those eager beavers who started with T cell counts above this level.

In the largest of these studies, the proportion of people living during the 2 years of follow-up was 96% for those with a T cell count of 200 and above when they started HIV treatment. For those who began meds with a count between 150-199 the survival rate dropped to 90%. If therapy was started at lower T cell counts things were far worse: T cell=50-99 - 78% survival at 2 years, 0-49 - an abysmal 65% survival.

So clearly people can live, even without opportunistic conditions with low T cell counts but the odds of remaining free of problems diminishes as the counts drop.

In the setting of HIV infection in most, but not all, cases the T cell count falls over time. A value of 200 or less must be placed in the context of the values that preceeded it. Had there been a downward trend in counts? Or, were they stable at 500-600 for years and now there is a single level that is much lower. I would check an unexpected value again before freaking out about any lab result.

Everything we know at present, and some common sense, indicates that it is all about the T cell counts. Levels of these cells below 200 or so should be avoided. Thanks - DW



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