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Odds of Severe Side Effects vs. Odds of Developing OIs

Oct 21, 2003

Dear Doctor: With some horror, I have read on this website some of the possible side effects of anti-HIV meds. Particularly troubling is the occurrence of heart attacks and liver complications. I wonder, how does one balance the odds of developing a severe negative reaction to the meds. vs. the likelihood of developing OIs without the meds. I mean, I obviously want to avoid developing any OIs, but if it means I may drop dead of a heart attack or liver failure , or have to take a seeminly endless number of medications (e.g., to reduce cholesterol, lipid levels, etc.), then I don't know if it's worth it. I'm relatively sure I know what your response will be, but I just wanted to bring this issue out for discussion. Thanks!

Response from Dr. Pierone

Risk assessment is based on likelihood of occurrence. As I was exiting a recent early morning jet trip the pilot said "the safest part of your day has just ended, be careful on those highways". Commercial air travel (per mile) is safer than auto travel, much safer. But many people are much more apprehensive about air travel despite the evidence that car trips are much more likely lead to injury and death. The chances of dying in a road accident on a motorcycle are 28 times higher than dying in a car. So we can stratify risks and try to make life decisions based our risk tolerance.

In the case of HIV treatment we are really balancing the risks of treatment versus the risks of AIDS-related complications. The extremes are easy. For those with CD4 of <20 the risk of death in one year is very high (30%, plus or minus) and the one year risk of treatment is very low. For those with CD4 count of 1000 and low viral load the risk of progression to AIDS is virtually zero for at least several years and medications can be deferred because of their potential toxicity and costs. For those in the middle (the majority) we don't know exactly when the scales tip towards treatment versus watchful waiting. As we gather more experience we will get a better sense of when to start treatment.

When the decision to treat is made we then shift our focus to relative risks and benefits of the different cocktails. Do we chance liver toxicity with regimen A or cholesterol increase with regimen B or heightened depression with regimen C? What about regimen D which is the extremely potent, but a newcomer, so we don't yet know the long-term risks? Most HIV doctors think hard about these issues. A recent survey from the American Academy of HIV Medicine indicated that the majority of the members considered risk of heart attacks into consideration and the influenced their prescribing decision. Hope this helps. GP

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