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Factors in lifespan with CD4 350+ versus 350-
Mar 18, 2014

Dear Doctor,

I'm writing in regard to the research findings today posted on The Body web site regarding average lifespans for the HIV-infected with CD4s above 350 at time of initiating therapy versus less than 350. The study reports that those starting above 350 may expect a normal or above-normal lifespan. This seems like good news, but what I find so maddening about this and similar reports periodically appearing on this web site is that they leave out the important qualifying information, thereby rendering the findings useless for a reader except as generalized feel-good or feel-bad "lite" reading.

For instance, I'm 53, have had HIV for 29 years, am currently undetectable, and take Atripla as my only therapy. Clinically, I'm doing well. I started Atripla therapy in 2005 with CD4 of 210, and most recently it was around 750. I've never been ill from HIV, and do not have Hep C, nor have I ever injected drugs, etc. Now to the point: what exactly are the factors that should make my lifespan shorter than normal while having initiated therapy with a CD4 of less than 350? The study cited on this web site very coyly, vaguely alludes to "other variables" (I'm guessing injection drugs, hep C, mental issues, homelessness, etc.) without ever addressing how any of this should be considered when assessing the significance of having started therapy with an initial CD4 count of more or less than 350.

This kind of report, although well meaning, is almost worse than nothing because it doesn't offer information that one could relate to a real-life situation. It's just empty numbers. So what do you think? How should an average reader such as myself with a starting CD4 count of less than 350 make sense of this news? Is starting with CD4 of less than 350 but no history of injection drugs, hep c, or HIV symptoms functionally equivalent to starting with CD4 over 350? If not, then what are the negative factors? Insofar as you are publishing this on your web site as an research summary, and setting up hierarchies of clinical outcomes, I think you should be a bit more clear about what you are trying to communicate to the public.

Thanks for your attention on this.

Response from Dr. Young

Hello and thanks for posting.

You're referring to the North American ACCORD study that reported last year that life expectancy among positives in the US and Canada has increased steadily in recent years. This is entirely great news, and is true whether one starts treatment "early" (with CD4s greater than 350) or "later" (with CD4s below 350).

But whoa there. What you're at issue with is the observation that populations of people who start treatment later have a lower average life expectancy than those who start earlier. I'm sorry that you're upset about the reporting about this- it's merely the data that was presented.

There are some obvious reasons why this would be the case- first off, populations of people who start treatment later include people who are also diagnosed with AIDS complications. This later group is at much greater risk of death from these complications, so by simple math, would tend to drag down the average life expectancy of the group. There may be other reasons too- those who access care late also tend to have difficulty staying productively in care once diagnosed, so many social issues can also cause problems- the very issues that you've mentioned. The difficulty in these studies is that not every contributing research group was able to faithfully capture these data, so it's difficult to draw any detailed conclusions.

This doesn't (as you suggest) make the study useless. On the contrary, knowledge that the pathway that we're taking-- to try to get people to test earlier, stay in care and on treatment is have dramatic impacts-- in these studies, minimally measured by life expectancy. These are studies of tens of thousands of real people, with real lives. I wouldn't so quickly dismiss the conclusions. I wouldn't be so discouraged by the report- this report is a cup way full, not meaninglessly empty.

Life expectancy is improving and is normal on average. It's overly dismissive that you don't think that knowledge of late diagnosis and initiation of treatment isn't important for the thousands of people who are not tested or not productively engaged in their health care.

Remember the study that we've discussed (and others) are population-based studies. Other studies have and do address factors that negatively affect health risk. Many of them conclude that for people like you with normal-range CD4 counts and on treatment have very similar disease risks as the general population. Different types of studies look at individual risk- a relevant one shows that current CD4 count is important too. Risk of complications (including heart disease and death, for example) are now essentially the same as the HIV negative population once one has recovered a CD4 count to above 750 or so-- these conclusions meaningfully apply to you.

How should you interpret these results? It means that if you have risks factors noted in a population of people in one study, one should look carefully if any of these risks apply to you. To the extent that late initiation is a factor, you can't control that. But making sure that you stay engaged in your care, adherent to your medication and involved in as much preventive medical care (diet, exercise, smoking cessation, vaccinations) as possible.

In the end, while you may disagree with the reporting, but know that if you're on treatment, adherent, have an undetectable viral load and normal CD4 count, I'd be plan on an average, if not longer than average life expectancy.

Hope that's helpful. BY



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