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Ask the Doctor: At What T-Cell Count Should a Person Begin Treatment?

March 15, 2011

Every month, HIV specialist Theresa Mack, M.D., M.P.H. -- an associate medical director St. Luke's Roosevelt Morningside Clinic, a comprehensive HIV-care center in Harlem, N.Y. -- will answer your most pressing HIV/AIDS questions.

Every month, HIV specialist Theresa Mack, M.D., M.P.H. -- an associate medical director St. Luke's Roosevelt Morningside Clinic, a comprehensive HIV-care center in Harlem, N.Y. -- will answer your most pressing HIV/AIDS questions.

In December 2009, the Department of Health and Human Services issued new guidelines (pdf) to encourage health-care providers to counsel newly diagnosed HIV-positive patients to start taking HIV-fighting medicine as soon as possible after receiving their diagnosis. Earlier recommendations had suggested that patients start taking medications when their CD4, or T-cell, count dropped to 350 or below. The new recommendations, which were modified in January 2011, advise patients to start antiretroviral medications even when their T-cell count is above 350.

But the new advice has been hotly debated. Some experts still believe that treatment should not be initiated until the T-cell count drops below 350. Concerns involve the possibility that the person will become resistant to medication, experience adverse side effects or have a hard time adhering to the treatment regimen. Dr. Mack weighs in.

According to the previous guidelines, treatment was offered to and initiated in asymptomatic patients with a T-cell count of 350 or lower. However, treatment is and always has been initiated in any patient with symptoms, regardless of his or her T-cell count. The new guidelines recommend that, regardless of a patient's T-cell count, HIV treatment should be started.

Supporters of the new guidelines believe that the sooner patients begin antiretroviral treatment, the more likely that they will preserve their immune systems and prevent AIDS-related complications, infections and cancers, since the newer drugs are more effective and better tolerated.

Opponents think that not enough information is available about the potential short- or long-term complications and the risk of developing drug resistance. Resistance to a medication means that it will not work for you. However, your immune system can be repaired even if you begin medications later. It is important, though, that medications begin before your immune system has been seriously damaged; that is, before your T-cell count falls to 200 or below.

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HIV medications, like any medications, may have side effects. However, not everyone will experience them. Your body may react differently from someone else's. It is vital that you discuss your concerns with your HIV-care provider. More importantly, and fortunately, HIV medicines have changed this disease from a fatal one to a chronic illness.

For so long, HIV/AIDS experts have been preaching the message, "If you don't have any symptoms, you can wait to start treatment," so it's easy to understand why patients are leery of starting medication. "If it's not broke, don't fix it," they think. When I bring the topic up, overwhelmingly, my patients want to wait. They say, "No, I'm fine. My quality of life is good." But whether you are on medications or off them, regular checkups with your provider are necessary to identify problems early.

On the flip side, there are patients who began taking HIV medicines at higher T-cell counts long before the guidelines changed and are doing well.

Either way, as a doctor, I abide by what my patients want, need and feel that they can tolerate. It is a partnership: Information is exchanged both ways. The goal is to help patients maintain or improve their quality of life.

As told to Tomika Anderson, a freelance writer based in Brooklyn, N.Y.


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