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Author Topic: Doctor to me: That's what my patients who are dead used to say.  (Read 1146 times)

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Offline indianguy1984

  • Member
  • Posts: 15
Doctor to me: That's what my patients who are dead used to say.
« on: January 05, 2013, 05:26:30 AM »
Been infected for 1 year.

My labs are CD4 522 23%
VL is like 19000+
CD4/CD8 ratio of 0.42% which is low.

When I told my Yale trained Head of ID Dept doctor I am hopeful there'll be better medication that is fixed dose once a day and my CD4's still ok.

She said in a matter of fact tone - That's what my patients who are dead used to say. They're dead now you know.

Apparently it is advocated to start HAART the moment you're infected?

I am a psych nurse working 3 shift crazy shifts - I can't do Atripla because I had one bout of depression in the military in my country. I can't deal with diarrhea farting in morning ward round when attendings are all staring at you - so am worried about the combinations.

She suggested Raltegravir + Truvada - I am flying off to India on 22nd Jan to buy 1 year supply of it.  I am looking for the combination which is the least toxic, least side effects and she suggested this.
Aug 2011 - Negative
Nov 2011 - ELISA+ve WB Indeterminate
Dec 2011 - CD4 472 VL 1868 copies/ml CD4% 27
Jan 2012 - CD4 577 VL 3575 copies/ml CD4% 27
Aug 2012 - CD4 551 VL 16156 copies/ml CD4% 21
Dec 2012 - CD4 522 VL 19600 copies/ml CD4% 23
My birthday - 30 Jan 2013 - Started Isentress+Truvada

Offline spacebarsux

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  • Posts: 1,350
  • Survival of the Fittest
Re: Doctor to me: That's what my patients who are dead used to say.
« Reply #1 on: January 05, 2013, 10:22:48 AM »
Been infected for 1 year.

My labs are CD4 522 23%
VL is like 19000+
CD4/CD8 ratio of 0.42% which is low.

When I told my Yale trained Head of ID Dept doctor I am hopeful there'll be better medication that is fixed dose once a day and my CD4's still ok.

She said in a matter of fact tone - That's what my patients who are dead used to say. They're dead now you know.

Apparently it is advocated to start HAART the moment you're infected?


With due respect to your doctor, given your present lab numbers this is ridiculous hyperbole, Yale degree or Cambridge degree.

Your doctor is from the 'hit hard, hit early' school of thought, which is a perfectly defensible position. But then there are umpteen doctors and experts who belong to the 'wait and see' camp which is also a legitimate position, given the science.

It is arguable that no major reduction in risk of illness or death has been conclusively shown for HIV treatment with a CD4 count over 350/500, so waiting might be perfectly valid. Even in the US treatment over a CD4 count of 500 is contested by many, even if in the end the guidelines did not reflect this (it was in the draft). Do note that the guidelines in Europe, India as well as in other parts of Asia reflect treatment only when CD4 falls to 350.

Some points on both sides of the argument, benefits and disbenefits eg see here:

http://i-base.info/htb/20331.

Also, Here’s a link that delineates the benefits and limitations of early initiation of HAART. (i.e. CD4>500).

http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/10/initiating-antiretroviral-therapy-in-treatment-naive-patients

Portion relevant for you:

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.
 
When discussing starting ART at high CD4 cell counts (>500 cells/mm3), clinicians should inform patients that data on the clinical benefit of starting treatment at such levels are not conclusive, especially for patients with very high CD4 counts. The same is true for individuals with low viral load set points at presentation and for “elite controllers”. Further ongoing research (both randomized clinical trials and cohort studies) to assess the short- and long-term clinical and public health benefits and cost effectiveness of starting therapy at higher CD4 counts is needed. Findings from such research will provide the Panel with guidance to make future recommendations.


There's a more detailed analysis of you peruse the link.
« Last Edit: January 05, 2013, 10:25:30 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 eric48

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  • Posts: 1,011
  • @HIVPharmaCure & tinyurl.com/HIVPharmaCure
Re: Doctor to me: That's what my patients who are dead used to say.
« Reply #2 on: January 05, 2013, 06:25:18 PM »
Hi,
Technically, your CD4/C8 ratio should be read as 0.42 (and not 0.42 %, which equals 0.0042)
Your CD8 (with a ratio of 0.42) is 1242.

If it where 100 times more, you would have 124200 CD8 !

So let's make this correction: your CD4/CD8 ratio is 0.42
Below 1.0 is a hallmark of active infection.
Yet 0.42 is NOT very low. it is kind of average for an HIVer with out meds
Mine was 0.25 (it is now 1.23)
So
A- it is not THAT low
B- in each of strata of immunologic recovery <200; 200-350 ; 350-500 ; 500+ about 50% revert to 'normal' value , i.e. > 1.0.

So even many people under meds have a ratio similar or even lesser that your.

The clinical relevance of this ratio is debatable, anyway.

So even if you go on meds and your ratio remains at ca. 0.5, this is not a matter of major concern.

Me, I am of this 'older' generation that lost so much to the virus.
Regardless of what side effects of the meds might be, the virus is NASTY

The medical concensus is a bit in favor of starting earlier, even though this is a recommendation that does not qualify for 'strong' recommendation

I, personnally , do not see much very strong reason not to start meds early.

That being said, if you are having 'crasy' schedules, you should not underestimate that convinience of once daily dosing.

There are many once daily. Some of them just one pill, others with 2-3 pills. who cares. they just take a little more room in a pill case...

I am on Viramune+Epzicom: once daily 2 pills

Viramune is said to give less side 'brain' side effects than Efavirenz (the suspect in Atripla)
I still have some sleep issues but can not say which of the meds causes that

Hope this helps

eric

 

Offline indianguy1984

  • Member
  • Posts: 15
Re: Doctor to me: That's what my patients who are dead used to say.
« Reply #3 on: January 05, 2013, 08:23:01 PM »
Oops - yeah it is 0.42 and not 0.42%  :-*

I am scared to take medication - the idea of missing doses, resistance, wiping out the available drug classes to use scares me - I wish they came up with monthly depot injections for HIV - We give it to our psychiatric patients here who can't be compliant to medications.

Sigh.
Aug 2011 - Negative
Nov 2011 - ELISA+ve WB Indeterminate
Dec 2011 - CD4 472 VL 1868 copies/ml CD4% 27
Jan 2012 - CD4 577 VL 3575 copies/ml CD4% 27
Aug 2012 - CD4 551 VL 16156 copies/ml CD4% 21
Dec 2012 - CD4 522 VL 19600 copies/ml CD4% 23
My birthday - 30 Jan 2013 - Started Isentress+Truvada

Offline aztecan

  • Member
  • Posts: 5,358
  • 28 years positive, 56 years a pain in the butt
Re: Doctor to me: That's what my patients who are dead used to say.
« Reply #4 on: January 06, 2013, 12:10:46 AM »
I have been taking the regimen you are talking about taking.

I have taken it for years without problem. It is probably the easiest and less intrusive regimen I have been on.

You may be surprised at how anticlimatic starting meds actually can be, rather like taking your vitamins or eating lunch.

Let us know how you are doing.

HUGS,

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

Offline Rockin

  • Member
  • Posts: 491
Re: Doctor to me: That's what my patients who are dead used to say.
« Reply #5 on: January 07, 2013, 05:40:58 AM »
Oops - yeah it is 0.42 and not 0.42%  :-*

I am scared to take medication - the idea of missing doses, resistance, wiping out the available drug classes to use scares me - I wish they came up with monthly depot injections for HIV - We give it to our psychiatric patients here who can't be compliant to medications.

Sigh.

I think your fear is understandable but, to be honest, I cannot even fathom going about my life knowing that the little beast is running wild inside my body...worrying if my VL is increasing too much or not every single day, and not only that, but also scaring away possible affairs for not being in an UND status.

I live my life in peace knowing the meds are keeping the virus in a sort of "sleeping" state. It makes me feel much better and I'm glad for my meds. I respect your fears and your decision, but you should also consider this.

 


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