Patient Choice and the Decision to Start
To further emphasise the urgency of immediate treatment, Dr. Cohen says that the concept of a person being "ready to start" treatment suggests that a doctor-patient discussion to arrive at this position might project "a false sense of security" that "all is well."
This central tenet of treatment guidelines -- readiness to start -- is one that activists have demanded and supported because of a high risk of failure when the need for treatment and how to use it is not understood. Whether someone is starting treatment on diagnosis, using a CD4 threshold of 500, 350 or 200 -- for their personal health or to reduce the risk to their partner -- it needs to be an informed choice.
Throughout the interview, language is used that increases anxiety, rather than providing information for an informed choice. This includes the "urgency" discussed above, but also emphasises the fear of the unknown. An HIV diagnosis is still traumatic for most people. It is a life-changing event. The decision to start treatment is similarly important.
Scaring people into the decision, whether for future health risks or on a public health agenda, will help no-one.
The plausibility of potential benefits of treatment on diagnosis has been argued since AZT monotherapy. No virus is better than virus. But at high CD4 counts there is too little evidence to know whether lifelong treatment is better than asymptomatic HIV.
Currently, the evidence (and expert interpretation of the same evidence in different guidelines) still supports equipoise for many people on the question of whether benefits outweigh the risks of earlier treatment at CD4 counts above 350. Results from the START study, expected in 2016, will provide the strongest real data to inform this question.2
This doesn't mean nothing can be done until then, but guessing the results -- or worst still, pretending the evidence already exists -- has a serious risk for being wrong.
HIV positive people should have the option to start treatment at any CD4 count, especially to reduce the risk of transmission to sexual partners. But to be an informed choice, this needs to acknowledge that the evidence for personal health benefits at high CD4 counts has plausibility, but limited data.
Until 2016, a wide range of studies suggest both a low absolute risk from starting earlier treatment if this is an individual's choice and a low absolute risk from deferring until 350 if that is an individual's choice. This is especially important to remember for people enrolled in the START study, who will ultimately help settle this key question.
Simon Collins is a member of the Community Advisory Board for the INSIGHT group that is currently running the START study. This article was based on a previous weblog.25 Thanks to the HTB editorial board for support and comments.
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