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mac prophylaxis
Jun 9, 1997

my recent cd4 was 2 in dec 1996. after starting 3 drug therapy my count increased to 150. My doctor deciced to discontinue Zmax for MAC prophylaxis. I have had many negative MAC cultures. Was this the right decision or should I continue on Mac prophylaxis? I currently feel better than have in years.

Response from Dr. Cohen

The "party line" on this controversial question is that you should base prophylaxis decisions on the lowest CD4 count you've have ever had. That means that if you've ever been below 50, you should take MAC prophylaxis regardless of what your CD4 count is now.

The reason for this approach is that if, when you had a CD4 count of 2, you had lost all of the CD4 cells that remembered how to fight MAC, you would not have recovered them after starting your triple drug therapy. You would simply have more of whatever CD4 cells you had at your lowest point. Unfortunately, there's no way to test for those cells, so there's no way to know whether you are now able to fight MAC. That's why the recommendation is that you continue prophylaxis.

All that being said, I have to say that I sometimes "break the rule" and stop prophylaxis in people who have done very well on antiretroviral therapy and who look a lot better clinically. I haven't been "burned" yet, knock on wood, but there are reports of people developing opportunistic infections at unusually high CD4 counts when those counts are a result of therapy.



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