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Is It Safe To Wait?
Jul 21, 2002

Hi Dr. Young. First of all i'd like to say thanks for all the hard work you and your colleagues do for us on this great site and hope you had an informative and productive time at the XIV Aids Conference in Barcelona.

My question is this - having paid close attention to the news that has come out of the conference - am i right in thinking that it's now ok to wait untill CD4 counts drop to 200 before initiation of HAART. I have been pos for nearly a year now, My viral load has never been lower than 100.000 and CD4 count has fluctuated between 260 and 415. My doc wants me to start HAART but because i'm so scared of the side effects i want to delay treatment for as long as possible. In your opionion and given thre lastest news from Barcelona - do you think its ok for me to wait until my CD4 count gets to 200 before i start treatment or am i playing 'Russian Roulette' with my health. Your thoughts are greatly appreciated. Craig

Response from Dr. Young

Thanks for your question and comments. Good to know that folks out there are following the meeting coverage here (and presumably at other sites).

There has been much made of recent studies that suggest delaying therapy until CD4 counts reach 200 cells. Lost in this simple one-number fits all summary are lengthy discussion about viral load levels (like yours, at 100,000,quite high) that, independent of CD4 count may place you at early risk of HIV disease progession. Indeed, even most recent, and conservative guidelines would have you and your doctor consider initiation of treatment in the near future with your numbers.

I'd also point out that the debate about when to start is long from settled-- recent analysis (some from my partner, Ken Lichtenstein, from the US/ CDC HOPS cohort; others from the APROCO cohort in Italy) suggest strongly that the risk for developing lipodystrophy (lipoatrophy, specifically) increases dramatically with lower nadir (lowest ever) CD4 counts-- if so, then waiting for levels below 200 would place you at greater risk for this very serious and difficult to treat complications. Indeed, delayed therapy at one level was rationalized to prevent the emergence of toxicities-- these data would argue the opposite might occur, at least with regard to lipodystrophy.

Personally, I'd want to pre-emptively make sure that everything was in place to maximize your support system, adherence education and evaluation of treatment choices, then start therapy in the near term (provided that everything else was in good order). I believe that there are clearly risks and benefits to treatment-- but when one weighs the risk of AIDS-related complications with a high viral load, I think that the burden of data suggests starting earlier than 200 CD4 cells.

Hope this is helpful. BY



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