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Your reasoning about when to start HAARt
Sep 24, 2007

As someone who is also considering starting HAART after my CD4 has dropped from 620 when i was diagnosed a year ago to 380 now, I read your response on August 21 "when to start HAART' with interest and confusion. You seem to imply the only reason for not starting HAART at any CD4 level was due to cost and resources. I am based in the UK, where the pharmaceutical industry has less obvious clout due to restricted marketing practices, and where the guidelines are less bullish about starting HAART than in the UK, but everyone has free access to meds. The arguments we hear are about using up treatment options unnecessarily early and many side effects (for instance, one example from many: the recent report about 65 per cent of people on HAART suffering cognitive impairment within 6 months*), yet your reponse to this person with a CD4 of 520 made no mention of either of these issues. Is this because you believe they are overstated or incorrect? And while I very much appreciate this website, I truly hope that the support and ads from the drugs companies doesn't colour the advice you are giving. I look forward to hearing your reply.

* Robertson KR et al. The prevalence and incidence of neurocognitive impairment in the HAART era. AIDS 21: 1915 1921, 2007

Response from Dr. Henry

The issue of when to treat is a complicated one and often needs to be individualized. The overall risk for AIDS over the next year in a person with a CD4 count > 350 and a modest (ie < 40,000 copies/mml) viral load is low (< 8%) so to treat all persons > 350 would expose 92/100 persons to HIV treatment without a clinical AIDS benefit over that time period (though it would protect their immune system). There is an increased risk for non-AIDS HIV related disease for persons with a CD4 count < 500 that is still being quantitated but is modest for those with CD4 count between 350-500. For persons with a CD4 count > 500 and a low-modest viral load there is a low risk for any HIV-related clinical events for the next several years. Tracking the changes in CD4/RNA level over time while providing good education about the pros and cons of HIV therapy and managing other medical problems well is often a prudent options for persons with high CD4 counts (> 500). As the drugs get better with fewer side effects and more options if resistance develops, arguments about withholding therapy for those reasons are less persuasive. Stopping treatment often results in a period of increased risk for health problems and a reversal of the gains afforded by treatment so the decision to start treatment is a weighty one since the intention at this point is indefinite (life long) treatment likely extending many decades. If I sound confused on this it is because the topic is controversial and there is no randomized study even open that will provide a good answer in the near future. Cost benefit analysis are often applied to issues around patient populations (that is one place where costs of care and resourcs enter the picture) but those often don't apply so well to an individual patient who is well served by being followed by an open minded HIV specialist who can make an indivualized recommendation heavily influenced by the patient's view of their health. KH



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