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Author Topic: U.S. DHHS treatment guidelines Updated. ART recommended for all HIV+ Individual  (Read 4492 times)

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Offline buginme2

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Initiating Antiretroviral Therapy in Treatment-Naive Patients
The Panel updated its recommendations on initiation of ART in treatment-naive patients. The changes are primarily based on increasing evidence showing the harmful impact of ongoing HIV replication on AIDS and non-AIDS disease progression. In addition, the updated recommendations reflect emerging data showing the benefit of effective ART in preventing secondary transmission of HIV. The updated section includes more in-depth discussion on the rationale for these recommendations and on the risks and benefits of long-term ART. The Panel's recommendations are listed below.

ART is recommended for all HIV-infected individuals.

The guidelines now "strongly" recommend treatment at <500 CD4 cells and "moderately" recommend starting treatment at > 500 CD4 cell count.

http://www.thebody.com/content/66414/whats-new-in-the-us-dhhs-antiretroviral-therapy-gu.html?ic=700100

Don't be fancy, just get dancey

Offline newt

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The recommendations for starting at a CD4 count under 350 and one between 350 to 500 are strong (read: pay attention) and based on 1 or more randomised controlled trials. The recommendation on starting at a CD4 counts of over 500 is moderate (read: take it or leave it) and based on expert opinion. I understand this as not quite all people recommended for treatment immediately, there is some equivocation about treatment at higher (500+) CD4 counts.  I agree with the expert opinion in favour of treatment regardless of CD4 count, but others might not, and that is a fair call.

Treatment when pregnant, with a history of an "AIDS-defining illness" (see usual list), presence of HIV related kidney disease and hepatitis B coinfection are all strong recommendations. The notes on earlier treatment for older folk and treatment to reduce the risk of transmission are useful and older age/wishing to reduce transmission are good reasons to start treatment.

This is not much different to the new UK guidelines, except the recommendation on starting with a CD4 count in the 350-500 range being stronger.

- matt
"The object is to be a well patient, not a good patient"

Offline mecch

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Well this is good news. 
I also like the way prevention is considered.

Also, to me it seems like a step towards normalisation of HIV as just another disease that deserves medicine.  And money to pay for that medicine.  Countries have to find a way to fund treatment for everyone who wants it, or needs it, and also a way to lower transmissions.  Since nobody is FORCING treatment on anyone, isn't it a win win that official guidelines give a rationale for treatment since funders will be pushed to pay for it accordingly.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline leatherman

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And money to pay for that medicine.
and that's a serious problem. Like all guidelines, these are only "guidelines" not written-in-stone "rules", and definitely un-funded; so therefore a true problem to actually implement.

in a state that already doesn't have enough funding to treat the patients that fit the "old" guidelines (416 on the SC ADAP waiting list as of 3/23), these newer guidelines might as well be written on the wind for all the good they will do here towards giving people healthier lives and reducing the transmission rates of HIV in this state.
Sigh!
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline spacebarsux

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Since nobody is FORCING treatment on anyone, isn't it a win win that official guidelines give a rationale for treatment since funders will be pushed to pay for it accordingly.

I don't see it as a win-win situation until there is incontrovertible scientific proof of a 'net benefit' of ARV therapy with CD4>500. If and when the evidence of treatment advantage with high CD4s attains an overwhelming force, these guidelines will be accepted globally, which they are presently not and there are valid reasons for this- that are also based in HIV science.

« Last Edit: March 30, 2012, 03:58:24 AM by spacebarsux »
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline mecch

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You personally can wait for some "incontrovertible scientific proof"!   

But in the meantime plenty of doctors think its a fine idea NOW, and a DHHS announcement gives some more authority, so its up to insurance companies and governments to figure out to how to afford all this.

I think bias and fear about HIV does shadow the treatment guidelines, which are supposed to be based on medical knowledge but feel often "shadowed" by cost of treatment of this disease.  Sometimes blatently.  Often unspoken. Particularly in countries that find it hard to afford treatment. 


“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline spacebarsux

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You personally can wait for some "incontrovertible scientific proof"!   

But in the meantime plenty of doctors think its a fine idea NOW, and a DHHS announcement gives some more authority, so its up to insurance companies and governments to figure out to how to afford all this.

I think bias and fear about HIV does shadow the treatment guidelines, which are supposed to be based on medical knowledge but feel often "shadowed" by cost of treatment of this disease.  Sometimes blatently.  Often unspoken. Particularly in countries that find it hard to afford treatment.

It’s got nothing to do with what I personally think, nor what you do. It’s about what scientific data tells us.

If there are many doctors who think it’s a wise decision to start treatment right away (and I understand they have cogent reasons), there are probably just as many, if not more, (within the US as well as all over EU and Asia) who think it is prudent to wait and see.

Moreover, your “bias and fear about HIV does shadow the treatment guidelines” argument appears more valid for early commencement of treatment as current data does not indicate any discernible benefit to an individual from shoving pills into his/her body with CD4>500; however there is a clear benefit in respect of reduction in onward transmission (by over 96%).

I’d actually be very interested to know more about the reasons behind this intellectual discord amongst the medical/scientific community in the US (even within) and EU, Asia regarding the timing of therapy commencement and how much weight was given to public health issues (as opposed to individual health), financial burden of treatment and HIV science.
 
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline Miss Philicia

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(...as well as all over EU and Asia)

This is about the Department of Health & Human Services guidelines. They don't give a fuck about you damn foreigners, nor do I.

USA #1!
"I’ve slept with enough men to know that I’m not gay"

Offline spacebarsux

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This is about the Department of Health & Human Services guidelines. They don't give a fuck about you damn foreigners, nor do I.

USA #1!

I thought you had the hots for latinos? Or only the ones who're US citizens ?  :o LOL
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline Miss Philicia

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I thought you had the hots for latinos? Or only the ones who're US citizens ?  :o LOL

You're confusing eroticizing someone and actually caring.
"I’ve slept with enough men to know that I’m not gay"

Offline spacebarsux

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You're confusing eroticizing someone and actually caring.

Liar. We all know how much you care for all our AIDS ridden faggoty asses, even the ones in Latvia.

PS- No offence to anyone in Latvia.  :)
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline Jeff G

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Foreigners with low viral loads are hot .

Offline Growler

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I don't see the logic in waiting for a CD4 count to reach an arbitrary number or for the diagnosis of an AIDS defining condition before offering reatment. Can any one name any other transmissible disease where guidelines specify delaying treatment after diagnosis until the point is reached where damage to the body is already being done?

GROWLER
“If loving someone is putting them in a straitjacket and kicking them down a flight of stairs, then yes, I have loved a few people.”

Offline Miss Philicia

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I don't see the logic in waiting for a CD4 count to reach an arbitrary number or for the diagnosis of an AIDS defining condition before offering reatment. Can any one name any other transmissible disease where guidelines specify delaying treatment after diagnosis until the point is reached where damage to the body is already being done?

GROWLER

No, but there's a long history of HIV medications that had side effects that didn't show up instantly, but several years further into treatment. Hence why many err on the side of delaying treatment if the patient has enough numerical wiggle room. Personally I think they're better able to test in clinical trials these days for certain suspected toxicities so that's less of an issue currently, but there's still always the possibility for something unknowable and delayed to occur.
"I’ve slept with enough men to know that I’m not gay"

Offline mecch

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I don't see the logic in waiting for a CD4 count to reach an arbitrary number or for the diagnosis of an AIDS defining condition before offering reatment. Can any one name any other transmissible disease where guidelines specify delaying treatment after diagnosis until the point is reached where damage to the body is already being done?

GROWLER


Yeah, pretty much my point too. Thanks!
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline mecch

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  • red pill? or blue pill?
Moreover, your “bias and fear about HIV does shadow the treatment guidelines” argument appears more valid for early commencement of treatment as current data does not indicate any discernible benefit to an individual from shoving pills into his/her body with CD4>500; however there is a clear benefit in respect of reduction in onward transmission (by over 96%).

Shoving pills huh.  Have you considered this turn of phrase might reveal a kind of emotional baggage you have about HAART?
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline mecch

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  • red pill? or blue pill?
No, but there's a long history of HIV medications that had side effects that didn't show up instantly, but several years further into treatment. Hence why many err on the side of delaying treatment if the patient has enough numerical wiggle room. Personally I think they're better able to test in clinical trials these days for certain suspected toxicities so that's less of an issue currently, but there's still always the possibility for something unknowable and delayed to occur.
I agree with this caveat, as well.  And, so called "early treatment" is optional.  Patient gets to choose with his/her doctor.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline Hellraiser

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It’s got nothing to do with what I personally think, nor what you do. It’s about what scientific data tells us.

If there are many doctors who think it’s a wise decision to start treatment right away (and I understand they have cogent reasons), there are probably just as many, if not more, (within the US as well as all over EU and Asia) who think it is prudent to wait and see.

Moreover, your “bias and fear about HIV does shadow the treatment guidelines” argument appears more valid for early commencement of treatment as current data does not indicate any discernible benefit to an individual from shoving pills into his/her body with CD4>500; however there is a clear benefit in respect of reduction in onward transmission (by over 96%).

I’d actually be very interested to know more about the reasons behind this intellectual discord amongst the medical/scientific community in the US (even within) and EU, Asia regarding the timing of therapy commencement and how much weight was given to public health issues (as opposed to individual health), financial burden of treatment and HIV science.

Whoa, cat.

Your opinion is just as much fiction as mecch's while yes there are no studies that say treament at 500+ CD4 is useful there are also no definitive studies saying that a viral infection running rampant in your body completely uncontrolled is the best path to go either.  I'm a firm believer that having the virus under control and dealing with the side effects of the drugs is the better option.  Had I been diagnosed with a 1000+ CD4 I still would have gone onto medication as soon as I could.  This is really a two way street and neither party can be proven correct.  You think the drugs are worse whereas I believe even low level viremia is worse.

Offline spacebarsux

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I don't see the logic in waiting for a CD4 count to reach an arbitrary number or for the diagnosis of an AIDS defining condition before offering reatment. Can any one name any other transmissible disease where guidelines specify delaying treatment after diagnosis until the point is reached where damage to the body is already being done?

GROWLER

Yes, people who are infected with the TB bacteria but the infection is latent (and if they are not immuno-compromised etc) are often advised to not go on treatment right away if doctors think there is no risk of the infection turning active. This is not uncommon.

Likewise, with HIV, the logic is based in HIV science and data that weighs up the pros and cons of treatment side-effects (long term and short term) and the ill-effects of the virus (long term and short term) before suggesting whether or not therapy is necessary at a given point in time of HIV infection.

The above, is not my opinion, it is the rationale behind all treatment guidelines, US or otherwise. It’s not as simplistic ‘put someone on therapy since they’re now infected with HIV’. If this were the case, why even bother with checking your CD4s prior to starting treatment? In fact, why bother with guidelines at all?

I never claimed to spout medical opinion. I am merely highlighting the fact that the recommendation/suggestion to begin therapy with high CD4s is (a) based on expert opinion and not on clinical trials (which isn’t the case with CD4s at 350 or lower, which are backed by data);  (b) that such an opinion lacks consensus even within the medical community; and (c) the clear benefit of a reduction in onward transmission was taken into account in the DHHS guidelines (granted this is very important, but it doesn’t take away the fact that this is more pertinent from a public health standpoint rather than individual benefit).

Shoving pills huh.  Have you considered this turn of phrase might reveal a kind of emotional baggage you have about HAART?

As for the term “shoving pills”, it was less my opinion on HAART than a response to Mecch’s facetious remark: “You personally can wait for some "incontrovertible scientific proof”.

As it happens, I am starting to lean more in favour of early therapy as well, since studies have indicated that long-term use of HAART is safe. If Mecch, Hellraiser or others provide links to studies stating there is a clear net-benefit from early commencement of HAART, I’d gladly shut up. I’d actually be happy to. However, until then prattling about what many doctors think in no way mitigates what many others do. Even if they’re not American and don’t agree with you. This is all that my point is.
« Last Edit: March 31, 2012, 03:54:07 AM by spacebarsux »
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline aztecan

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Yes, people who are infected with the TB bacteria but the infection is latent (and if they are not immuno-compromised etc) are often advised to not go on treatment right away if doctors think there is no risk of the infection turning active. This is not uncommon.

Likewise, with HIV, the logic is based in HIV science and data that weighs up the pros and cons of treatment side-effects (long term and short term) and the ill-effects of the virus (long term and short term) before suggesting whether or not therapy is necessary at a given point in time of HIV infection.

Sorry, but you are mistaken, at least in the U.S.

TB infections, even if latent, are not left untreated here. In fact, it is one of the reportable diseases and one which the government can actually force you to treat.

Regarding HIV, there is ample evidence, both through studies and anecdotal observations, that indicates long-term HIV infection is detrimental to a person's health even in the absence of advanced HIV disease.

The other reasoning in the NIH recommendation is the reduction in the chance of transmission of HIV thanks to low or undetectable viral loads brought about by ARV therapy.

The real argument here is going to be, "Who will pay for this?"

HUGS,

Mark
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline bocker3

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I never claimed to spout medical opinion. I am merely highlighting the fact that the recommendation/suggestion to begin therapy with high CD4s is (a) based on expert opinion and not on clinical trials (which isn’t the case with CD4s at 350 or lower, which are backed by data);  (b) that such an opinion lacks consensus even within the medical community; and (c) the clear benefit of a reduction in onward transmission was taken into account in the DHHS guidelines (granted this is very important, but it doesn’t take away the fact that this is more pertinent from a public health standpoint rather than individual benefit).

So let's see, you state that there is lack of consensus, yet you take that to mean don't start early and others take that to mean, let's start early.  Who's right?  Who's wrong?  I submit that neither are.  One can find a study and/or interpret studies to back up either opinion.  So, your arguments hold as much water as Mecch, Hellraiser and anyone else who is on the opposite side of yours.  That, my dear, are the reality based facts -- not the emotional ones or the self-interpreted ones. 

Starting early or not is a PERSONAL decision. 

We get it, you are not a fan of starting meds "early" -- you seem to have an overwhelming fear of possible side effects, so feel free to share your opinion on it, but stop trying to present it as a fact vs. what it is -- an opinion (or YOUR interpretation of SOME of the data).

Oh -- and these "expert opinions" you are talking about -- are they some of the same "experts" who keep spouting off about needing to not share toothbrushes or razors to avoid transmitting the virus?  Yes -- these are true experts, aren't they.

Mike
Atripla - Started 12/05
Reyataz/Norvir - Added 6/06
Labs - Pre-Meds
Sep05 T=350/25% VL98,559
Nov05 288/18%  47,564
Current Labs
May2013 691/31% <20

Offline spacebarsux

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Sorry, but you are mistaken, at least in the U.S.

TB infections, even if latent, are not left untreated here. In fact, it is one of the reportable diseases and one which the government can actually force you to treat.


@Aztecan/Mark- With due respect, I never said latent TB is left untreated. I said immediate treatment isn’t always recommended. I checked before I posted about that.

Here is an excerpt from the NYC Guidelines for Testing and Treatment of Latent TB Infection:

An individual not at high risk for developing TB disease who has been inadvertently tested should, generally, not be considered for treatment, even if the test result is positive. However, treatment for LTBI is generally recommended for children with LTBI, regardless of risk factors.

Link: http://www.nyc.gov/html/doh/downloads/pdf/tb/ltbi_guidelines.pdf

So let's see, you state that there is lack of consensus, yet you take that to mean don't start early and others take that to mean, let's start early.  Who's right?  Who's wrong?  I submit that neither are.  One can find a study and/or interpret studies to back up either opinion.  So, your arguments hold as much water as Mecch, Hellraiser and anyone else who is on the opposite side of yours.  That, my dear, are the reality based facts -- not the emotional ones or the self-interpreted ones. 

Starting early or not is a PERSONAL decision. 

We get it, you are not a fan of starting meds "early" -- you seem to have an overwhelming fear of possible side effects, so feel free to share your opinion on it, but stop trying to present it as a fact vs. what it is -- an opinion (or YOUR interpretation of SOME of the data).


What I am stating is fact and NOT opinion, namely:

I never claimed to spout medical opinion. I am merely highlighting the fact that the recommendation/suggestion to begin therapy with high CD4s is (a) based on expert opinion and not on clinical trials (which isn’t the case with CD4s at 350 or lower, which are backed by data);  (b) that such an opinion lacks consensus even within the medical community; and (c) the clear benefit of a reduction in onward transmission was taken into account in the DHHS guidelines (granted this is very important, but it doesn’t take away the fact that this is more pertinent from a public health standpoint rather than individual benefit).


The lack of medical-opinion consensus is not what I think, it is a fact. Also, nowhere in this thread have I stated that I’m not a fan of early treatment (in fact, I have stated I am leaning towards early treatment), nor have I said it is not or should not be a personal decision. This is something you and/or Mecch have inferred and/or are using to undermine the facts that I’ve presented.

Fact remains, mounting evidence of detrimental effects of long term HIV-infection (with high CD4s) notwithstanding, until we have clearer proof from the START study of a net-benefit regarding commencing therapy with high CD4s, we just can’t say for sure either way. That’s all that I was, and still am, highlighting.

Like I said before, I’d most happily bow out of this argument if anyone provides links of studies stating, in no ambiguous terms, that there is a net-benefit from early initiation of HAART (this is different to harmful effects of viral multiplication). There’s nothing out there yet. It will become clear when the START study releases its results.

Again, I say this not to counter or support an argument of delaying treatment but merely to stress that the argument of starting treatment early on doesn’t exactly rest on the strongest underpinnings either- because if it did, the medical community would unanimously agree on dispensing with this entire notion of treatment guidelines and put people on therapy as soon as they’re diagnosed, in the US and everywhere else in the world. They currently do not, they’re not idiots and they do have valid scientific reasons.
« Last Edit: March 31, 2012, 02:46:27 PM by spacebarsux »
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline phildinftlaudy

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BTW -
On March 29, 2012, a document titled "Corrections to Adult and Adolescent ARV Treatment Guidelines" was issued:

http://aidsinfo.nih.gov/contentfiles/upload/Corrections_AdultARV_032912.pdf

September 13, 2008 - diagnosed +
Labs:
Date    CD4    %   VL     Date  CD4  %   VL
10/08  636    35  510   9/09 473  38 2900  12/4/09 Atripla
12/09  540    30    60   
12/10  740    41  <48   
8/11    667    36  <20  
03/12  1,041  42  <20
05/12  1,241  47  <20
08/12   780    37  <20
11/12   549    35  <20
02/12  1,102  42  <20
11/12   549    35  <20

Offline nixsmail

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i don't often post because i just enjoy the site for what it is, information, HIV and otherwise but the topic of TB hits me close to home and i feel that this needs a first hand response. While putting the following information out there gives up private medical info i feel that it's worth it to clarify.

where i work we are required to have a yearly TB skin test and up til oct 2010 mine had always been negative and it is not known at work that i'm pos. well in oct, the 7th to be specific, of 2010 the day after the administration of the skin test it was entirely red and itchy and reactive. went to the doc to get a reading and was not expecting the resultant actions to just a reactive test.

i was first put in a negative airflow room to isolate me, then multiple docs, with face masks, came in to examine and poke around. a sputum sample was taken and an immediate x-ray request done. i donned a mask to go to x-ray and several shots were taken. went back to the negative room awaiting the doc's return. doc came back and we discussed now what. that result was that i was to go home immediately no stopping anywhere and i was not to leave the house until the public health dept contacted me. couldn't even go to my office to pick things up. the doc said that the control was now with public health not with my doc's or myself. now mind you this is without any confirmation of active or inactive TB. public health contacted my at home that same day and advised that they would be by the next day to interview me and to fill out some forms. they arrived at the scheduled time and proceeded to tell me that until any test confirming either inactive or active TB was processed i was to stay at home. had to sign a paper to that effect indicating that under potential arrest that i would do so. in addition when i was sent home it was with 4 different drugs to start me on the TB meds. public health also set up someone to come by each day to actually watch me take the drugs. also required by them was a weekly sputum test for ongoing testing which they picked up at the time of the pill taking.

6 weeks later after multiple tests and pill taking they determined that my TB was inactive and that in addition to TB inactive i also had mac a TB close relative but not contagious, you know the disease back in the mid 80's that made HIV pos people look like walking dead. and it was active. needless to say all in all i was off work from oct to feb the next year and i am still on prophylactic for both TB and mac.

so public heath does get involved in a very big way when it comes to TB. they really don't wait for a confimation to start things up. now mind you this was in ca not ny so it may be different for different states but i find it difficult to believe that it is that different.
09/05/07 Officially diagnosed +4yrs at the time
11/06/07 CD4 624 (18%) VL 43,200
05/04/09 CD4 272 (15%) VL 521,190
06/10/09 CD4 127 (13%) VL 626,376 Started Truvada/Prezista/Norvir
07/15/09 CD4 849 (20%) VL 379
09/09/09 CD4 594 (21%) VL 68
01/28/10 CD4 706 (23%) VL 127
05/27/10 CD4 655 (22%) VL 322
07/29/10 CD4 750 (22%) VL 220
10/22/10 CD4 669 (23%) VL 65
12/27/10 CD4 720 (24%) VL 270
03/08/11 CD4 644 (23%) VL 631
07/27/11 CD4 694 (23%) VL <20
03/09/12 CD4 601 (20%) VL UND
11/07/12 CD4 693 (23%) VL UND
04/17/13 CD4 559 (23%) VL UND
11/07/13 CD4 846 (24%) VL UND
03/28/14 CD4 869 (24%) VL UND

Offline mecch

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  So, your arguments hold as much water as Mecch, Hellraiser and anyone else who is on the opposite side of yours.  That, my dear, are the reality based facts -- not the emotional ones or the self-interpreted ones. 

Starting early or not is a PERSONAL decision. 

Thats my view too. I don't advocate people start early. I am content by the DHHS announcement.  So a person can discuss whats best for him/her with the doc, and starting is a defensible option no matter the numbers.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline spacebarsux

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Thats my view too. I don't advocate people start early. I am content by the DHHS announcement.  So a person can discuss whats best for him/her with the doc, and starting is a defensible option no matter the numbers.

Of course starting early is defensible (It is known that untreated longterm HIV is bad). But so is delaying.

It wasn’t I, who gave an argument to delay or start early any sort of slant or colour, but it was you who first stated that it was a ‘win-win situation’- which it clearly is not, based on holistic view of the current data and opinion, as stated in the guidelines itself. That was my only point.

Since you and some others seem to think that I’m dredging up arguments/interpretations to push a late treatment philosophy, I’ll simply quote the ‘Potential Limitations of Early Initiation of ART’-which despite all the benefits of early treatment, can’t be glossed over- stated in the guidelines (that I was getting at):

"Patients with CD4 counts >500 cells/mm3

The NA-ACCORD study also observed patients who started ART at CD4 counts >500 cells/mm3 or after CD4 counts dropped below this threshold. The adjusted mortality rates were significantly higher in the 6,935 patients who deferred therapy until their CD4 counts fell to <500 cells/mm3 than in the 2,200 patients who started therapy at CD4 count >500 cells/mm3 (risk ratio: 1.94, 95% CI: 1.37–2.79) [11]. Although large and generally representative of the HIV-infected patients in care in the United States, the study has several limitations, including the small number of deaths and the potential for unmeasured confounders that might have influenced outcomes independent of ART.

In contrast, results from 2 cohort studies did not identify a benefit of earlier initiation of therapy in reducing AIDS progression or death. In an analysis of the ART-CC cohort [6], the rate of progression to AIDS/death associated with deferral of therapy until CD4 count in the the 351 to 450 cells/mm3 range was similar to the rate with initiation of therapy with CD4 count in the 451 to 550 cells/mm3 range (HR: 0.99, 95% CI: 0.76–1.29). There was no significant difference in rate of death identified (HR: 0.93, 95% CI: 0.60–1.44). This study also found that the proportion of patients with CD4 counts between 451 and 550 cells/mm3 who would progress to AIDS or death before having a CD4 count <450 cells/mm3 was low (1.6%; 95% CI: 1.1%–2.1%). In the CASCADE Collaboration [12], among the 5,162 patients with CD4 counts in the 500 to 799 cells/mm3 range, compared with patients who deferred therapy, those who started ART immediately did not experience a significant reduction in the composite outcome of progression to AIDS/death (HR: 1.10, 95% CI: 0.67–1.79) or death (HR: 1.02, 95% CI: 0.49–2.12).

With a better understanding of the pathogenesis of HIV infection, the growing awareness that untreated HIV infection increases the risk of many non-AIDS-defining diseases (as discussed below), and the benefit of ART in reducing transmission of HIV, the Panel also recommends initiation of ART in patients with CD4 counts >500 cells/mm3 (BIII). However, in making this recommendation the Panel notes that the amount of data supporting earlier initiation of therapy decreases as the CD4 count increases to >500 cells/mm3 and that concerns remain over the unknown overall benefit, long-term risks, and cumulative additional costs associated with earlier treatment.


POTENTIAL LIMITATIONS OF EARLIER INITIATION OF THERAPY


Although there are benefits associated with earlier initiation of ART, there also are some limitations to using this approach in all patients. Concerns about long-term toxicity and development of resistance to ARV drugs have served as a rationale for deferral of HIV therapy. However, evidence thus far indicates that resistance occurs more frequently in individuals who initiate therapy later in the course of infection than in those who initiate ART earlier. Earlier initiation of ART at higher CD4 counts (e.g., >500 cells/mm3) results in greater cumulative time on therapy. Nevertheless, assuming treatment will continue for several decades regardless of when therapy is initiated, the incremental increase in drug exposure associated with starting therapy at higher CD4 counts will represent a small percentage of the total time on ART for most patients.

Newer ARV drugs are generally better tolerated, more convenient, and more effective than drugs used in older regimens but there are fewer longer term safety data for the newer agents. Analyses supporting initiation of ART at CD4 counts >350 cells/mm3 (e.g., NA-ACCORD and ART-CC) were based on observational data where patients were largely treated with regimens less commonly used in current clinical practice. In addition, these studies reported on clinical endpoints of death and/or AIDS disease progression but lacked information on drug toxicities, emergent drug resistance, or adherence. Therefore, in considering earlier initiation of therapy, concerns for some adverse consequences of ART remain.

Antiretroviral Drug Toxicities and Quality of Life

Earlier initiation of ART extends exposure to ARV agents by several years. The D:A:D study found an increased incidence of CVD associated with cumulative exposure to some drugs in the nucleoside reverse transcriptase inhibitor (NRTI) and PI drug classes [52, 126]. In the SMART study, compared with interruption or deferral of therapy, continuous exposure to ART was associated with significantly greater loss of bone density [60]. There may be unknown complications related to cumulative use of ARV drugs for many decades. A list of known ARV-associated toxicities can be found in Adverse Effects of Antiretroviral Agents.

ART frequently improves quality of life for symptomatic patients. However, some side effects of ART may impair the quality of life for some patients, especially those who are asymptomatic at initiation of therapy. For example, efavirenz (EFV) can cause neurocognitive or psychiatric side effects and all the PIs have been associated with gastrointestinal (GI) side effects. Furthermore, some patients may find that the inconvenience of taking medication every day outweighs the overall benefit of early ART and may choose to delay therapy.

Nonadherence to Antiretroviral Therapy

At any CD4 count, adherence to therapy is essential to achieve viral suppression and prevent emergence of drug-resistance mutations. Several behavioral and social factors associated with poor adherence, such as untreated major psychiatric disorders, active substance abuse, unfavorable social circumstances, patient concerns about side effects, and poor adherence to clinic visits, have been identified. Clinicians should identify areas where additional intervention is needed to improve adherence both before and after initiation of therapy. Some strategies to improve adherence are discussed in Adherence to Antiretroviral Therapy."

Link: http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/10/initiating-antiretroviral-therapy-in-treatment-naive-patients
« Last Edit: April 01, 2012, 02:24:43 AM by spacebarsux »
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline aztecan

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. . .
so public heath does get involved in a very big way when it comes to TB. they really don't wait for a confimation to start things up. now mind you this was in ca not ny so it may be different for different states but i find it difficult to believe that it is that different.

This is how it works here in New Mexico as well. While recommendations in New York may be different, I rather doubt actual practice is substantially different.

I have known five people here with TB and DOT (direct observational therapy) was required each time. The nurses had to see the person take the meds. In one case, one person had a habit of disappearing and had to be hunted down. As a result, he nearly wound up in jail in quarantine.

Thanks for your input.

HUGS,

Mark
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline leatherman

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TB infections, even if latent, are not left untreated here. In fact, it is one of the reportable diseases and one which the government can actually force you to treat.
of course, comparing anything TB-related to HIV is comparing apples to oranges.

TB is an easily communicable infecitous disease that needs to be medically stopped at the source to halt the start of an epidemic. HIV has nowhere near the same transmission abilities and so the threat is less immediate and treatment can be delayed.
leatherman (aka mIkIE)


chart from 1992-2013; updated 2/09/13  Reyataz/Norvir/Truvada

Offline spacebarsux

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TB is an easily communicable infecitous disease that needs to be medically stopped at the source to halt the start of an epidemic.

People with latent TB (different to active TB) do not have TB symptoms and cannot spread infection.

http://tuberculosis.emedtv.com/latent-tuberculosis/latent-versus-active-tuberculosis.html
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline bocker3

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People with latent TB (different to active TB) do not have TB symptoms and cannot spread infection.

http://tuberculosis.emedtv.com/latent-tuberculosis/latent-versus-active-tuberculosis.html

Good lord but you love to pick nits and argue, now don't you.  Perhaps it is simply a need a to have the last word on things.   ::)
It is probably wise to treat even latent TB, as you never know when it might become active again -- which would make it communicable.

Mike
Atripla - Started 12/05
Reyataz/Norvir - Added 6/06
Labs - Pre-Meds
Sep05 T=350/25% VL98,559
Nov05 288/18%  47,564
Current Labs
May2013 691/31% <20

Offline spacebarsux

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Good lord but you love to pick nits and argue, now don't you.  Perhaps it is simply a need a to have the last word on things.   ::)
It is probably wise to treat even latent TB, as you never know when it might become active again -- which would make it communicable.

Mike

Not nitpicking or arguing. Pointing out FACTS, that's all. Not stating my opinion- nowhere have I stated what is or is not wise decison treatmentwise.

Don't like it, don't read it. Simple.

Perhaps it's your need to argue and undermine FACTS that don't to push forward your OPINION on matters ?  ::)
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline Ann

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Can any one name any other transmissible disease where guidelines specify delaying treatment after diagnosis until the point is reached where damage to the body is already being done?


Herpes.

I'm not sure if there are, in fact, any specific treatment guidelines concerning herpes, but it is often left untreated.

This is despite it being a transmissible virus and despite the fact that a person on prophylactic treatment is highly unlikely to cause onward transmission.

It's also despite the fact that active herpes lesions can and often do (when they're in the ano-genital region) lead to secondary bacterial infections in the patient. Also despite the fact that it's one fucking painful condition.

It's also often not treated despite the fact that it can cause blindness in infants when an active lesion is present in the mother's ano-genital region at birth.

This is all despite the fact that the med used to treat herpes - acyclovir - is one of the easiest to tolerate meds out there and most people do not experience a single side-effect.

As it's available as a generic, the cost is not prohibitive.

The development of drug-resistance to acyclovir is also very rare, if it happens at all. (I believe I read something about that only people with severely compromised immune systems have been known to develop resistance - not people in the general population.)

Just sayin'. I think the example of herpes may be slightly more relevant as an answer to the original question that produced the TB discussion. I'm pretty sure there are other examples as well. This has been brewing on the back-burner of my mind and herpes was the first to bubble to the top of the pot. I'll let you know what, if anything, else bubbles up. :)
« Last Edit: April 02, 2012, 08:28:14 AM by Ann »
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Offline Hellraiser

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Not nitpicking or arguing. Pointing out FACTS, that's all. Not stating my opinion- nowhere have I stated what is or is not wise decison treatmentwise.

Don't like it, don't read it. Simple.

Perhaps it's your need to argue and undermine FACTS that don't to push forward your OPINION on matters ?  ::)

You tend to always post, over and over again if someone disagrees with you.  This makes it seem as if you are very argumentative or defensive.  Just my take on it.

Offline spacebarsux

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You tend to always post, over and over again if someone disagrees with you.  This makes it seem as if you are very argumentative or defensive.  Just my take on it.

Yep, I have a tendency to be an argumentative ass as far as facts are concerned (Not opinon though). And what is stated in the guidelines is a fact, not my opinion. Sowie it bothers you.

Edited to add:- And I will go on the defence, if I am accused of making "my interpretation" of the guidelines to push forward a certain school of thought, when I have done no such thing.

You see, facts are sacred.
« Last Edit: April 04, 2012, 01:13:48 AM by spacebarsux »
Infected-  2005 or early 2006; Diagnosed- Jan 28th, 2011; Feb '11- CD4 754 @34%, VL- 39K; July '11- CD4 907@26%,  VL-81K; Feb '12- CD4 713 @31%, VL- 41K, Nov '12- CD4- 827@31%

Offline Miss Philicia

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You tend to always post, over and over again if someone disagrees with you.  This makes it seem as if you are very argumentative or defensive.  Just my take on it.

Would you like me to characterize your posts?

ps: spacebarsux is a law student so naturally he's intolerable.
"I’ve slept with enough men to know that I’m not gay"

Offline Hellraiser

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Sowie it bothers you.

I didn't say that it did.

 


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