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cd4 counts (WHEN TO START TREATMENT)
Oct 2, 2008

Doctor, i've noticed over the years (in fact over the course of a few short months), you've recommended med treatment at higher and higher cd4 counts. First, it was 200, then 250,... now, all of a sudden you're telling people that medical consensus says a whopping 350! What gives you the right to simply just keep rounding up and up and up, when you are advising people.

Other doctors here assure the reader that even if the person starts meds late, they can eventually get a good response.

If you're gonna say 350, cite your source,... and i hope its more than just a lone wacko doc you heard at a symposium in Mexico.

oh, and i'd love to see a control study of mortality comparison between someone on meds at whatever cd4 count verses people who never go on the meds.

Response from Dr. Frascino

WHOA! Calm down there hothead! First thing I want you to do is take three big cleansing yoga breaths. Go ahead. We'll wait. There, now don't you feel better and, hopefully, a bit less confrontational?

"What give you the right to simply just keep rounding up and up and up, when you are advising people?" Hmm . . . well, for starters, I'm the HIV physician specialist whose role is to advise (usually polite) questioners about HIV-related medical scientific facts and evolving medical treatment guidelines, based on a thorough review of peer-reviewed clinical trials and over a quarter of a century of personal experience treating thousands of patients with HIV/AIDS.

"Other doctors here assure the reader that even if the person starts meds late, they can eventually get a good response." In general I do not disagree with this statement and I have given similar advice many times. However, depending on when someone starts and many other variables (concurrent infections, host immune integrity, viral strain, adherence, tolerance, drug resistance, etc.), the more accurate statement would be ". . . they MAY eventually get a good response." There are no guarantees. And certainly there is absolutely no evidence suggesting that starting later (lower CD4 count) is better than starting earlier (higher CD4 count). In fact, there is growing scientific data suggesting just the opposite!

"If you're gonna say 350, cite your source . . . and I hope it's more than just a lone wacko doc you heard at a symposium in Mexico." I'll be more than happy to cite references (see below). As for "a lone wacko at a symposium in Mexico," I assume you are referring to the International AIDS Conference held in August in Mexico City and attended by nearly 30,000 scientists from around the globe. It was a bit larger in scope than a "symposium" of lone wackos.

Regarding your desire to see a "control study of mortality comparison between someone on meds at whatever CD4 count versus people who never go on meds," that clinical trial will never be done going forward, as to do so would be highly unethical based on what we know about antiretroviral therapy. Besides, the information you desire can be collected historically by looking at the morbidity and mortality data collected prior to the development of effective antiretroviral therapy (mid-1996). What you would clearly see, if you took a look, is that there has been what can only be considered an astounding and miraculous decrease in both morbidity and mortality since mid-1996 when HAART (highly active antiretroviral therapy) became widely available following the International AIDS Conference in Vancouver (another "symposium"?). For historical perspective, Netflix the PBS documentary "Age of AIDS." It chronicles the first 25 years of the pandemic. You could also try reading Randy Shilts's book "And the Band Played On."

As for why HIV treatment guidelines keep changing, please note this is an evolving epidemic. We continue to learn more and more about HIV pathogenesis and the natural history of the disease. In addition, as noted above, there have been (and continues to be) remarkable progress in developing new and novel approaches to treating HIV disease. In 1998, the U.S. Department of Health and Human Services created a panel of physicians, researchers and consumers to develop treatment guidelines. They constantly review AIDS research results. The treatment guidelines are updated almost annually based on the ever-evolving scientific and epidemiological data. The panel released the latest guidelines update in January, 2008. These are guidelines, not rules! All patients need individualized care from competent and compassionate HIV physician specialists. When it comes to HIV treatment, my motto is "One Size Fits One!"

To review the most recent and well referenced! guidelines from the U.S. Department of Health and Human Services (128 pages!!!), you can download a full copy at http://img.thebody.com/hivatis/pdfs/adult_guide.pdf. Check it out Mr. Hothead.

As for citing my references, please review the "SMART" study results. The Strategies for Management of Antiretroviral Therapy (SMART) Study Group was conducted in 318 international sites in 33 countries. A subset analysis of this study showed starting antiretroviral therapy at a CD4 count above 350 the current threshold for starting therapy based on the guidelines reduced risk of serious illness and death compared to beginning treatment later. (The full report is in the April 15th edition of the "Journal of Infectious Diseases.")

Current treatment guidelines in Europe and the U.S. recommend deferring antiretroviral therapy (ART) in asymptomatic adults until the CD4 count falls to 350 cells/mm3 or, in resource-poor countries, 200 cells/mm3. These recommendations were based on the results of nonrandomized studies and expert opinions.

The guidelines were formulated based on earlier concerns about the risk/benefit ratio of starting ART earlier and the fact that AIDS-defining clinical events (opportunistic infections, malignancies, etc.) were rare at higher CD4 counts. There were concerns that any benefits of early ART might be outweighed by toxicities, long- and short-term side effects, cost-effectiveness, quality of life issues, adherence and the development of drug resistance.

There is now an impressive and growing body of evidence to suggest that these guidelines should be revisited. First, data from clinical trials indicate that the risk of AIDS persists at CD4 counts greater than 500 cells/mm3. Second, even in patients with high CD4 counts, the risk of AIDS or death decreases with the initiation of ART when compared with that of those who are not on ART. Finally, the risk of serious non-AIDS-related diseases and cancers is lower at higher CD4 counts!

I could continue on and on about epidemiological reports from resource-poor countries where large numbers of HIV-infected individuals do not have access to ART. Tragically their morbidity and mortality figures are identical to what we witnessed here in the U.S. prior to the development and availability of potent effective antiretroviral therapy.

So, please continue to believe whatever you wish, but if you plan to ever return here with a question or problem, I strongly suggest you begin with an apology and ask your question in a more polite (or at least amusing) fashion.

Dr. Bob



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