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Author Topic: UPDATED 2/14 -- questions about CD4 counts after 6 year HAART study  (Read 3549 times)

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Offline Boo Radley

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See response # 32 for update to study information


I've had a question (or two) about this study since I read about it.  Besides the link I've copied a paragraph:

http://www.aidsmeds.com/articles/1667_11093.shtml

Quote
1/10/07    Title:  Early Treatment Linked to CD4 Gains

"...After six years of treatment, the average CD4 count was 493 among those who began therapy with 200 or fewer CD4 cells. Among those with CD4 counts between 201 and 350 at the time of treatment commencement, the CD4 count was approximately 508 after six years. Finally, among those who began therapy with CD4 cell counts above 350, the average CD4 count six years later was 829. ..."

First, it appears to me the CD4 counts of those who started <200 or <350 are basically the same -- 493 and 508.  Can someone explain the significance? 

Second, what percentages of any of the 3 groups experienced an OI or other AIDS-defining conditions once CD4 counts went and stayed above 200?

Third, what was the median CD4 count for the >350 group?  Several years ago the criteria called for HAART for counts below 500, so I am assuming a lot of people started HAART around that level. 

Finally, since I know answers to the questions above may not be available I'm going to precipitously jump to several conclusions of my own.

I'm assuming for #1 there is no real difference between 498 and 508.  I am also assuming that OIs and such were rare among participants once their CD4s reached 200 and above.  If the second assumption is correct my next question is what CD4 cell count constitutes good immune health?  My CD4 count was 220 last month but I have never had an OI so I'm assuming my immune system is still working adequately if not even well.

(Trying to grasp at the remaining straws before they all blow away...) Is it really surprising that people who started HAART with higher CD4 counts would have higher CD4 counts after 6 years?   Wouldn't it be interesting to track this group further to see what CD4 counts are like 7 and more years down the road, especially for those whose counts were at the low end?  If this year those who started below 200 reached 500 - 600 wouldn't that be a good indicator of improving immune health?

My (obvious) point is if my immune system is still intact and I've only been on HAART since October, 2004, in the long term it may have been wiser to start later because of drug toxicity over time.  I still agree with the current CDC HAART guidelines and always have and this study doesn't seem to contradict current guidelines.  Does it?  If so I'd really like to know, honestly. 

Does any of that make any sense (Doxie, you can ignore this question, thank you very much!)?

Boo
« Last Edit: February 14, 2007, 07:25:42 PM by Boo Radley »
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline dtwpuck

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Re: questions about CD4 counts after 6 year HAART study
« Reply #1 on: February 07, 2007, 09:00:55 PM »
Boo... I have been on a study since the first day I found out.  It's been ten years.  I started meds right away and have been on them for ten years as part of this study.  (along with the cross infection study)  Anyway, my counts are consistently in the 900's and I've not had a detectable VL since 1997.  Most of my health problems have been directly related to side effects and depression, but in any case, almost all of the people on this study report the same thing. 

So, while there are a lot of good, valid reasons not to go on therapy right away, there is also plenty of evidence that the "hit it hard and early" philosophy does have its merits.
Floating through the void in the caress of two giant pink lobsters named Esmerelda and Keith.

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #2 on: February 07, 2007, 10:15:42 PM »
So, while there are a lot of good, valid reasons not to go on therapy right away, there is also plenty of evidence that the "hit it hard and early" philosophy does have its merits.

Thanks for your response, puck.  I seem to have asked too many questions or maybe finally gone over the edge...

I want to ask one question about "hit it hard and early" as distinguished from the "hit hard, hit early" theory of HAART proposed by medical professionals like David Ho in the 90s.  I thought Ho abandoned his theory within a few years because starting HAART too early did not help to fight the virus sufficiently and seemed to be using meds that would be valuable later.  There is currently a school of thought that the guideline to start HAART at the 200 - 350 CD4 count may be lower than optimal for gaining the most benefits and their argument is sort of "hit hard early enough."   So, to come to the point, finally, you're not referring to the 90s theory but to one of more recent vintage? 

That is as clear as the Mississippi River water flowing past the port of New Orleans, isn't it?

Thanks,

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline dtwpuck

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Re: questions about CD4 counts after 6 year HAART study
« Reply #3 on: February 07, 2007, 10:23:36 PM »
No, I'm referring to the theory popular in the 90's which is when I started therapy.   
Floating through the void in the caress of two giant pink lobsters named Esmerelda and Keith.

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #4 on: February 07, 2007, 10:49:23 PM »
No, I'm referring to the theory popular in the 90's which is when I started therapy.  

So may I ask (and will you tell) what your CD4 and vl were at initiation of HAART?  Also, you mentioned side effects from meds -- did these cause you to stop using the particular meds, did you get over the side effects, or do you still have side effects being monitored?

If I'm getting too personal just say so.  I really thought Ho and others had backed off of the 90s theory but am always glad to be proved wrong in the interest of accuracy.

Thanks,

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline AustinWesley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #5 on: February 07, 2007, 11:58:45 PM »
This study has put my exact delima in a nut shell.   Mine are at 354 and I think after all the reports etc. I really won't be waiting much longer, maybe one more set of labs.

I feel that both sides have excellent points when it comes to starting early and waiting, but since it's my decision I really don't feel like letting my doctors gamble with my future anymore.   I believe I'm gona roll the dice on my own in favor of starting earlier.   

The other thing which was mentioned was age although I wish they'd specified more on that.  I just turned 37 so I tend to think for me it's the better decision now.  If I was 20, I'm not sure I'd have the same opinion.

I can read articles till my T cells dwindle to nothing or do something I guess.

Appreciate the post!
Diag. 3/06  Infected aprx. 2 mo. Prior
Date        CD4   %      VL
4/6/06     627    32    36,500     NO MEDS YET!
6/7/06     409    27    36,100
8/23/06   408    25     22,300
1/2/07     354    23     28,700
2/9/07     139    30     23,000  Hep A Vaccine same day???
2/21/07   274    26     18,500 
3/3/07    RX of Truvada/Sustiva Started.
4/5/07    321     27      Undectable 1st mo.  
5/16/07  383     28    Undectable 2nd mo.
8/10/07  422     32   UD <48 on new scale!

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #6 on: February 08, 2007, 12:23:53 AM »
This study has put my exact delima in a nut shell.   Mine are at 354 and I think after all the reports etc. I really won't be waiting much longer, maybe one more set of labs.

Wesley, I left my CD4s in the 350+ range for 6 - 9 months before they started dropping again.  Moron that I am I went about 5 months before getting blood work done and the CD4 was 169.  I started meds that week.   Don't let your count get anywhere near as low as mine but my (possibly, if not likely, faulty) reasoning was I was still healthy and never had a viral load over 30,000, and I'd never had any type of OI.  I am not a person who gambles or speeds excessively or does dangerous things for excitement so a CD4 count under 200 scared the beejezus out of me. 

Quote
... I just turned 37 so I tend to think for me it's the better decision now. 

Here chickie, chickie, chickie!  I was 48 (almost 49) when I started meds.

Quote
Appreciate the post!

Thanks!  I reciprocate the feeling!

Boo
« Last Edit: February 08, 2007, 02:10:34 AM by Boo Radley »
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline egello

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Re: questions about CD4 counts after 6 year HAART study
« Reply #7 on: February 08, 2007, 01:14:50 AM »
My ex is HIV poz, I wasn't while I was with him. He started the meds 9 years ago straight on for 4-5 years. He stopped and hasn't taken them for 4-5 years and he consistenly gets non detectable and good high cd4 count. He gets the blood work done every 3-6 months.

Me, when I got my thrush after about a month long diegestion problem, my cd4 count was at 11. And about two months after that PCP. So, what does that mean regarding the 200 mark point?
Reyataz / Norvir / Truvada/ Androgel 5 g / 2 days
1/29/07 14 T, 300 k V, 1.8 %
2/22/07 197 T, 247 V, 6.8 %
3/27/07 164 T, <50 V, 5.4 %
5/28/07 177 T, <50 V, 8.2 %
7/28/07 214 T, <50 V, 9.6 %
10/3/07 380 T, <50 V, 10 % no more Mepron, Famvir

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #8 on: February 08, 2007, 01:41:58 AM »
Me, when I got my thrush after about a month long diegestion problem, my cd4 count was at 11. And about two months after that PCP. So, what does that mean regarding the 200 mark point?

egello,

Many or most HIV medical professionals adhere to a med initiation guideline that states that 200 CD4 counts and below is a definite reason to start HAART.   

A CD4 count of 11 is a sign meds should have been started long before your CD4 count went that low -- that is why everyone who is sexually active should have regular HIV/STD testing and, if you're HIV+, regular monitoring of your CD4 count and viral load so you can begin HAART when it's wise to start.  The reason you got PCP is your immune system was still far too weak to combat the bacteria.   

You're really a pretty lucky person because not everyone who starts meds with a CD4 count of 11 will be strong enough to overcome opportunistic infections or tolerate HIV med or prophylaxis side effects.   

What was your most recent CD4 count and viral load?  What meds are you on?

Thanks!

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline egello

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Re: questions about CD4 counts after 6 year HAART study
« Reply #9 on: February 08, 2007, 02:09:12 AM »
egello,
You're really a pretty lucky person because not everyone who starts meds with a CD4 count of 11 will be strong enough to overcome opportunistic infections or tolerate HIV med or prophylaxis side effects.   

What was your most recent CD4 count and viral load?  What meds are you on?

what do you mean? your body has to be strong enough to tolerate hiv meds or prophylaxis? and also, my body wasn't strong enough to overcome OI since I got pcp.. Please clarify what you exactly meant, I am bit confused.

3 weeks ago before I started my HIV meds, my cd4 count was up higher at 16 YIPPIE
and viral load somewhat similar to when I got thrush.

I am on oh, jeesh

Truvada
Norvir
Reyataz

Azithromycin
Mepron
Fluconozole
Famvir

And whole loads of vitamins and minerals
Reyataz / Norvir / Truvada/ Androgel 5 g / 2 days
1/29/07 14 T, 300 k V, 1.8 %
2/22/07 197 T, 247 V, 6.8 %
3/27/07 164 T, <50 V, 5.4 %
5/28/07 177 T, <50 V, 8.2 %
7/28/07 214 T, <50 V, 9.6 %
10/3/07 380 T, <50 V, 10 % no more Mepron, Famvir

Offline Cheo63

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Re: questions about CD4 counts after 6 year HAART study
« Reply #10 on: February 08, 2007, 02:39:58 AM »
Hi Boo,

I must agree with Puck.   We both seem to have a very similar situation.   I started meds back on 1996 (that means, of course, that I've been on meds for over 10 years now!)   My cd4 counts has always been around 1100 except one time that it went down to 887.  The doctor explained why but I cannot remember the reason.  It was a couple of years ago.  My last lab test (10/06) showed cd4 count of 1247.  Oh, my vl has remained undectable since.   When I started my meds my cd4 count was 600.   So, of course, I am a believer of starting as early as possible.   I've been to the hospital three times but not one time was because of my HIV+ status!!!

Eli

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #11 on: February 08, 2007, 02:59:17 AM »
what do you mean? your body has to be strong enough to tolerate hiv meds or prophylaxis? and also, my body wasn't strong enough to overcome OI since I got pcp.. Please clarify what you exactly meant, I am bit confused.

Some people whose CD4 counts get very low (like yours at a very low 11) are already infected with one or more OIs that make them sick.  When you are already sick it can be hard to tolerate the side effects of HIV drugs like Truvada, Norvir, and Reyataz or to tolerate the side effects of the Azithromycin, Mepron, Fluconozole, and Famvir.  Since you seem to be doing well (like your awesome post earlier) it seems you are dealing with the meds.  You did get PCP but you apparently are able to control it with, I think... fluconozole since you no longer have PCP.   (I am assuming you don't have PCP any longer, egello -- is that true?)
 
I say you're lucky because some people who have such a low CD4 count as yours already have several infections that must be treated and they are weakened by the illnesses.  Adding the HIV drugs (Truvada, etc.) to the OI prophylactics [or treatments] (Azithromycin, etc.) with a person who is very sick can make it much more difficult for the person to control the OIs and adhere to HAART.    A friend of mine began HAART with a CD4 count in the 50s but he was already infected with 2 funguses that were affecting several internal organs.  He was too sick to take HIV drugs and the prophylactics and to tolerate the OI treatments with drugs like IV amphotericin-B three times a week.   You are taking all your drugs and having no major problems with side effects?  You are doing well and your future looks good.

egello, I don't write very well and have problems explaining simple things but what I mean to tell you is you seem to have gotten to the doctor in time to save your life.  It is more likely you will be alive 10, 20, or 30+ more years as the battle against HIV continues and treatment options expand to newer, less toxic drugs and other therapies. 

PM me if I'm still confusing you!

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #12 on: February 08, 2007, 03:11:25 AM »
I must agree with Puck.   We both seem to have a very similar situation.   ...   
I've been to the hospital three times but not one time was because of my HIV+ status!!!

Well, I better start reading up on all topics HIV again because I thought the practice of initiating HAART nowadays was based on the CDC guidelines.  Maybe I should read the guidelines again before I make a complete fool out of myself (TOO LATE!).

I've had 2 hernias repaired out-patient and a bicycle/car leg injury which required hospitalization and I lucked out for 3 weeks without a roommate.  But HIV has never sent me to the hospital, either!

Thanks for your response!

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline Cheo63

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Re: questions about CD4 counts after 6 year HAART study
« Reply #13 on: February 08, 2007, 03:16:57 AM »
Hey Boo,

You know, the funny thing is that my present doctor thought that my previous doctor was an 'Avant Garde' doctor.  However, I felt very comfortable and safe with my first doctor.  But boy, am I glad that my first doctor did start me off soon.  My present doctor is very good too.  But I feel that if I had had him first, he would have started me at a lower cd4 count.   Anyway, I am just glad to be where I am. 

The 3 hospital visits were due to my appendix!!  It's a long, long story but do to complications I ended up having two other surgeries due to this one.  Oh, also, I ended up with a hernia due to these surgeries so, there, I ended having 4 surgeries not 3!!

Eli

Offline dtwpuck

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Re: questions about CD4 counts after 6 year HAART study
« Reply #14 on: February 08, 2007, 05:37:37 AM »
So may I ask (and will you tell) what your CD4 and vl were at initiation of HAART?  Also, you mentioned side effects from meds -- did these cause you to stop using the particular meds, did you get over the side effects, or do you still have side effects being monitored?

If I'm getting too personal just say so.  I really thought Ho and others had backed off of the 90s theory but am always glad to be proved wrong in the interest of accuracy.

Thanks,

Boo


My CD4's were somewhere in the 400's when i started.  My VL was huge.  100000 plus.  But, after starting, my VL went gradually down over the course of a few month.  My CD4's went up to the 900 range and have stayed there fairly consistently, with a couple aberrations, like recently they were 700 for no reason.

Anyway, side effects have been my biggest issue. 
AZT.. projectile public vomiting.  severe anemia.  headaches
Crix... kidney stones
D4T  ... peripheral neuropathy
Sustiva ... severe horrible anxiety and depression
Abacavir... severe acid reflux.  *which I currently control with prevacid

Anyway, I finally found a combo which is manageable.  Epzicom (abacavir plus epivir) and Viramune.

As a side note, I also took Crestor for cholesterol.  I managed to be in the special group who can't tolerate that as well, and it gave me the worst muscle aches I have ever experienced.  Also I had the shakes, night sweats, and random fever spikes.  Boy, was I glad to get off of that!
Floating through the void in the caress of two giant pink lobsters named Esmerelda and Keith.

Offline egello

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Re: questions about CD4 counts after 6 year HAART study
« Reply #15 on: February 08, 2007, 11:15:38 AM »
the combo i am on is pretty mild in terms of side effects.
Reyataz / Norvir / Truvada/ Androgel 5 g / 2 days
1/29/07 14 T, 300 k V, 1.8 %
2/22/07 197 T, 247 V, 6.8 %
3/27/07 164 T, <50 V, 5.4 %
5/28/07 177 T, <50 V, 8.2 %
7/28/07 214 T, <50 V, 9.6 %
10/3/07 380 T, <50 V, 10 % no more Mepron, Famvir

Offline aztecan

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Re: questions about CD4 counts after 6 year HAART study
« Reply #16 on: February 08, 2007, 09:44:43 PM »
Like Puck, I started meds when my CD4s were in the 400 range, 440 I think.  My viral load was in the 60,000 range.

Three months after starting meds, my viral load was undetectable and my CD4s started rising. They now have stayed between 900 and 1,460 for nearly 11 years - with the exception of the last labs when I had a viral load of 61, which, I may add, chapped my butt.

I just checked my labs on Graph My Labs here and I was right, it was 440 something when I started my meds.

Unfortunately, I also noticed that my last CD4s dipped below 1,000, the first time since August 2003, that my CD4s have declined steadily for the past three labs (18 months) now down in the 900s, that my percentage has consistently dropped for the last three labs (18 months) and is now down to 38 percent, and as I mentioned earlier, I had my first detectable viral load since 1996 with my last results.

Sometimes I hate being so anal.

HUGS,

Mark
« Last Edit: February 08, 2007, 10:01:43 PM by aztecan »
"May your life preach more loudly than your lips."
~ William Ellery Channing (Unitarian Minister)

Offline aupointillimite

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Re: questions about CD4 counts after 6 year HAART study
« Reply #17 on: February 08, 2007, 10:05:18 PM »
I have also started early... with CD4s in the 470s and a vL in the 9,000 range.

To me, it just makes sense that preventing immune system damage with the newer drugs (which have less toxicity and side effects), and especially with quite a number seemingly heading down the pipelinne... is preferable to letting the immune system damage build up before starting meds. 

God only knows what else this virus does, and I like having it suppressed as much as I am able while my body is still more than strong enough to take care of itself.  I'm thinking of the meds as preventative maintenance for a couple decades down the road instead of a "oh God, you almost have AIDS, time to start gulping pills" measure.

But the pendulum seems to be swinging back in favor of early intervention.  Plus, I like feeling proactive by taking the meds... instead of watching an inevitable CD4 decline.  I'd rather kick ass first and ask questions later.

But that's just me... it's what my doc and I are comfortable with.
Your tastebuds can't repel flavor of this magnitude!

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #18 on: February 08, 2007, 11:18:13 PM »
To me, it just makes sense that preventing immune system damage with the newer drugs (which have less toxicity and side effects), and especially with quite a number seemingly heading down the pipelinne... is preferable to letting the immune system damage build up before starting meds. 

But... but, aupoint, the newer drugs haven't been out long enough to know what long-term effectiveness, without toxicity, will be.   I hope you're right that newer and expanded options for treatment will be available soon but I haven't seen many released on the market.   How many classes of drug exist and what percentage of HAART recipients have resistance to all of the current drugs? (rhetorical question, of course)

Also, mon ami, my immune system is still packing all the punches and last month the CD4s low-blipped at 220 but I'm not sick.  My immune system fought off the virus for 15 - 20 years before meds became necessary, and I see that as adding years to my life.  We know people who started off on AZT monotherapy in the 80s who are still alive today, but most of them are gone.  People are surviving today with a mix of NRTIs, NNRTIs, and PIs (and what else?) but the long-term effect on life expectancy of the newer drugs is unknown.

We're only 11 or so years into PIs and when people get to 20 years and beyond I'll be more optimistic about outlooks for HAART recipients.  What is available today is chemotherapy.  HIV illness is the first disease that requires lifetime chemotherapy.  I mean, golly gosh, AZT came off the shelves at NIH as a failed cancer chemo in the mid 80s.

Finally, remember HAART apparently only affects HIV in the bloodstream.  Large reservoirs of virus exist in the gut, lymphatic system, and a few other places I can't remember, and we have no treatments for those infections as of yet.  What is the use of living if your brain turns to mush because of HIV?  What if you need a new liver (you can have a part of mine, I'll never miss it) after 15 years on Atripla?  God forbid it should happen but we really don't know!!

I hope we're all correct in that starting HAART is an option each person (who has access to decent medical care) with HIV probably must consider at some point.   As long as the virus is stopped before it can do permanent damage maybe it doesn't ultimately matter that I started with a CD4 of 169 and Benj started at 470 and everyone else started at a different number.   

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline aupointillimite

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Re: questions about CD4 counts after 6 year HAART study
« Reply #19 on: February 09, 2007, 03:46:18 AM »
Boo, it was a gamble to start this early... but one I was willing to take... indeed, one that I wanted to take.  I know how new these drugs are... I know about potential, unimagined side effects down the road... and perhaps I jumped in a bit too soon... but I wanted to.  That's the crazy shit about HIV, even 25 years down the line... we don't know.  I certainly don't know... but trying to keep it down now seemed like a better option to me. 

I guess I'll know if I made the right decision in ten or twenty years... but even if I made the completely wrong decision... at least some other people will be helped. 
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Offline Tim Horn

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Re: questions about CD4 counts after 6 year HAART study
« Reply #20 on: February 09, 2007, 01:58:38 PM »
Hi Boo --

I just wanted to highlight the final paragraph of the article, which I really wanted to add to put the data in context:

Quote
Given limitations of the collected data, it was not possible to conclude that higher CD4 cell counts in those who began treatment early were necessarily associated with longer disease-free survival than those who achieved less pronounced CD4 count increases. Additional clinical trials evaluating the timing of treatment initiation on AIDS diagnosis and survival rates will likely be needed to answer this long-standing question.

The point I wanted to make here is that we really don't know what these data mean in terms of bona fide clinical benefits.  So, yeah, those who started therapy with a CD4 count above 350 saw their counts increase to higher levels than those who started therapy with CD4s below 200 and between 200 and 350.  But what does this mean? Is someone with a treatment-induced CD4 count of 800-something necessarily going to live a longer, healthier life than someone with a treatment-induced CD4 count of the high 400s/low 500s?  And is the difference between those with 493 CD4 cells six years into treatment and those with 508 CD4 cells six years into treatment at all significant?  This study definitely isn't the one to seriously weigh when trying to make sense of this long standing debate. 

The fact is, the most important goal of treatment is disease-free survival.  While CD4 cell counts and viral load are believed to be a "surrogate marker" of disease-free survival -- the lower the viral load and the higher the CD4 count, the lower the risk of disease progression -- we simply haven't yet seen concrete data answering, in no uncertain terms, when therapy should be started based on CD4+ cell counts. 

There have been data indicating that those who start therapy with CD4 cell counts below 200 are still at a higher risk for developing AIDS-related problems more than those who start therapy with CD4s above this level.  This is why the 200 CD4 cut off is pretty solid.  What we don't have are studies indicating showing that those who start therapy with a CD4 count between 200 and 350 are at a higher risk of developing AIDS related problems over five to ten years, than those who start therapy with a CD4 count above 500.  It's just not clear at all.

I do think the study being discussed here is interesting and does hint at an advantage associated with starting therapy "early."  But is it conclusive?  Not at all.  It's just one piece of the puzzle.  But until this puzzle presents a crystal clear picture, I do think that the DHHS guidelines (and those elsewhere in the world) suggesting that treatment definitely be started before the CD4 count falls below 200 is reasonable and sound, based on what we do (and don't) know thus far.

Tim Horn


Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #21 on: February 09, 2007, 02:29:01 PM »
Tim,

Thank you for your as-always helpful response.  Even though I read the entire article the final paragraph didn't seem to register.  That addendum alone pretty much took care of my inferences and guesses.

Boo
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Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline ChattyJay1

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Re: questions about CD4 counts after 6 year HAART study
« Reply #22 on: February 09, 2007, 05:31:36 PM »
Boo...i take it that you're referring to the Johns-Hopkins study that was recently released?  well it's not the first one to say that the "hit hard, hit early" technique works.  there's a lot of proof that it does work especially depending on where your CD4's are when you start med's.  It's why i started a bit early.  You will always be in my prayers :)
We should all be working together to make activism our first tool, and our first line of OFFENSE not Defense!!!  :-)

Offline AustinWesley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #23 on: February 09, 2007, 05:53:33 PM »
Hey Chatty,

I believe he's referring to the article that he provided the link to in starting the thread.

Boo, just wanted to say thanks again for posting this.   It helped me to come to my own decision.    Fortunately, I got rid of the bad doctor who told me to come back in 4 1/2 months.   I saw my prior doc. today and he ran a complete set of tests again which I should have in about a week.

Unless, I see any improvement I think I will be starting now.

One thing in particular was that he said with my numbers he agreed that I should likely start.  He also said he wouldn't have had me wait 4 1/5 to 5 months.  2 at very most.

Anyways, it was a decent visit with him and we talked about the thoughts of starting earlier vs. later; however, in my case my numbers have shown a consistent decline all the way around.

It's a gray and depressing day, and driving home I just had a horrible feeling of dread.   I'm not so much worried about starting the meds, but I regret waiting this long.   I couldn't help feeling like the numbers are showing I'm dying.  UGH!

Anyways, that's it for me today. 

Wesley
Diag. 3/06  Infected aprx. 2 mo. Prior
Date        CD4   %      VL
4/6/06     627    32    36,500     NO MEDS YET!
6/7/06     409    27    36,100
8/23/06   408    25     22,300
1/2/07     354    23     28,700
2/9/07     139    30     23,000  Hep A Vaccine same day???
2/21/07   274    26     18,500 
3/3/07    RX of Truvada/Sustiva Started.
4/5/07    321     27      Undectable 1st mo.  
5/16/07  383     28    Undectable 2nd mo.
8/10/07  422     32   UD <48 on new scale!

Offline ChattyJay1

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Re: questions about CD4 counts after 6 year HAART study
« Reply #24 on: February 09, 2007, 06:10:20 PM »
Austin...i was right...he WAS referring to the Johns-Hopkins study results  ;)  sorry, i just knew the quotes that he had of all the numbers.  yeah, that wuz the Johns-Hopkins study that just recently got released.   I meant NO offense hun :)
« Last Edit: February 09, 2007, 06:21:48 PM by ChattyJay1 »
We should all be working together to make activism our first tool, and our first line of OFFENSE not Defense!!!  :-)

Offline AustinWesley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #25 on: February 09, 2007, 07:35:56 PM »
Oh, well I missed something then.  Boo?  Where is this other study?

Sorry, I must be half dazed from prior events today.

Diag. 3/06  Infected aprx. 2 mo. Prior
Date        CD4   %      VL
4/6/06     627    32    36,500     NO MEDS YET!
6/7/06     409    27    36,100
8/23/06   408    25     22,300
1/2/07     354    23     28,700
2/9/07     139    30     23,000  Hep A Vaccine same day???
2/21/07   274    26     18,500 
3/3/07    RX of Truvada/Sustiva Started.
4/5/07    321     27      Undectable 1st mo.  
5/16/07  383     28    Undectable 2nd mo.
8/10/07  422     32   UD <48 on new scale!

Offline ChattyJay1

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Re: questions about CD4 counts after 6 year HAART study
« Reply #26 on: February 09, 2007, 07:41:37 PM »
Wesley, I'm sorry that you had such a bad day.  Here's the explanation:  the link that Boo lists at the top of the thread refers to the Johns-Hopkins study.  I hope that you are feeling better about things soon! ;)
We should all be working together to make activism our first tool, and our first line of OFFENSE not Defense!!!  :-)

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #27 on: February 09, 2007, 08:22:31 PM »
I really must be losing it...

I thought I'd posted a response to this an hour ago but I must have gotten distracted.  Shiny objects and kittens with whiskers...

My reference was to the linked article by Tim Horn in AIDSmeds news section.  His article may indeed refer to Johns Hopkins (and going back to try to find out is how I've gotten distracted... this is like Lost Weekend).  ChattyJay1 may be perfectly correct that all or part of the study is also referred to as the JH study.

I spent so much damned time eloquently and persuasively exploring this issue but I'm posting now before this nihilist gem gets trashed, too.

Boo
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline siongi

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Re: questions about CD4 counts after 6 year HAART study
« Reply #28 on: February 12, 2007, 04:27:20 AM »
 someone please enlighten me with this thing about blood work?

Offline Boo Radley

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Re: questions about CD4 counts after 6 year HAART study
« Reply #29 on: February 14, 2007, 03:54:02 PM »
The link below has additional information about this topic (i.e., the 6 year Johns Hopkins study), which seems to make the answer a little more clear.  You can use the link below to read the AM post and link to the Medscape summary, but below the link I pasted the full Medscape summary of the study:

     
When to Start Meds -- Study on Long-Term Response


Summary from Medscape cited in the post above:

"Long-Term CD4 Response: Where You Start Predicts Where You End Up

AIDS Clin Care.  2007; 2007 Massachusetts Medical Society
Posted 02/08/2007

After 6 years of successful antiretroviral therapy, the only patients likely to achieve a low-to-normal CD4-cell count were those who had started treatment with >350 cells/mm3; counts stopped increasing after 4 years, regardless of the baseline count.
Summary and Comment
Summary

Most patients on potent combination antiretroviral therapy achieve undetectable viral loads, but CD4 responses to therapy are more heterogeneous. In this study (previously reported at the 13th Retrovirus Conference), investigators analyzed CD4-cell counts in a large group of patients with sustained virologic suppression.

Eligible patients were identified from the Johns Hopkins HIV Clinical Cohort based on the following criteria: (1) receipt of potent PI- or NNRTI-based combination therapy; (2) sustained virologic suppression to <400 copies/mL for at least 6 months; and (3) no history of treatment interruption. If viral rebound occurred after suppression, data were censored to record the CD4-cell count at the last visit before rebound.

A total of 655 patients met the inclusion criteria; their median treatment duration was 46 months (range, 1372 months). When stratified by baseline CD4 count (<200 cells/mm3, 200350 cells/mm3, >350 cells/mm3), patients with >350 cells/mm3 had lower viral loads, were less likely to be black or to use injection drugs, and were more likely to have acquired HIV through male-to-male sexual contact. They were also more likely to be treated with an NNRTI-based regimen than with a PI-based one.

After 6 years of treatment-induced virologic suppression, patients in the three strata achieved the following median CD4-cell counts:

    * 493 cells/mm3among those who started treatment with <200 cells/mm3,

    * 508 cells/mm3 among those who started treatment with 201350 cells/mm3, and

    * 829 cells/mm3 among those who started treatment with >350 cells/mm3.

"Normal" CD4-cell counts (≥750 cells/mm3) were achieved by 12%, 21%, and 46% of the three groups, respectively. All three groups experienced a plateau in CD4-cell increase after 4 years of therapy, with no significant increase after this point. Multivariate analysis revealed that a higher baseline CD4-cell count predicted a better CD4 response, whereas injection drug use and older age predicted a lower one. No differences were seen based on type of therapy (NNRTI- vs. PI-based) or coinfection with hepatitis C virus.
Comment

The strengths of this analysis are the relatively large sample size and the long-term follow-up, with the latter allowing for a clear description of a CD4 plateau effect. Although one could argue that the difference between a "final" achieved CD4 count of approximately 500 cells/mm3 versus 800 cells/mm3 is not clinically meaningful, such a difference could have important implications for the development of neoplastic and chronic inflammatory complications. In addition, we should remember that each of the median values in this study describes a range of CD4 responses, with the lowest strata including individuals with persistently low CD4-cell counts despite virologic suppression. These findings and those from a similar study in Europe [Abstract 530, 13th Retrovirus Conference, Denver, 2006] are already widely cited as evidence supporting a higher CD4 threshold for initiating antiretroviral therapy in asymptomatic patients.

Paul E. Sax, MD

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Citation(s)

    * Moore RD and Keruly JC. CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression. Clin Infect Dis 2007 Feb 1; 44:441-6."
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline Boo Radley

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UPDATED 2/14 -- questions about CD4 counts after 6 year HAART study
« Reply #30 on: February 14, 2007, 04:01:31 PM »
Below is the text of my response in Treatment Questions to the study summary link.  I don't have much to add other than I appear to be wrong in my "wait until it's almost too late" theory of HAART initiation.  Now I'm so freaked I'm gonna get scammed out of thousands of dollars trying to find some substance to boost the CD4 count:

"Henry,

The summary of the article includes key information I had not read before:

"After 6 years of successful antiretroviral therapy, the only patients likely to achieve a low-to-normal CD4-cell count were those who had started treatment with >350 cells/mm3; counts stopped increasing after 4 years, regardless of the baseline count."

If the increase in CD4 counts levels off after four years that's rather important!  If this is accurate the CDC guidelines may need to be changed again and people should start HAART when their CD4 count is in, let's say, the 400-500 range.

Then again, we don't know what the average minimum CD4 count is for a healthy immune system.  Probably varies somewhat from person to person but most people who have CD4 counts >400 still seem to be in good health.   If the immune system is uncompromised at a count of >400 and after 4 years of HAART one's CD4 count is in the 500 - 600 range, are these counts more likely to lead to future immune problems than counts in the 600 - 800 range?

Thanks for this extremely interesting and informative link!

Boo"

This information really changes the picture as far as I'm concerned, assuming it is correct. 
« Last Edit: February 14, 2007, 04:07:20 PM by Boo Radley »
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

Offline Boo Radley

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Re: UPDATED 2/14 -- questions about CD4 counts after 6 year HAART study
« Reply #31 on: February 14, 2007, 07:27:07 PM »
bump, bump, bump
bump, bump. bump
shake your booty

K.C. and the Sunshine Band
String up every aristocrat!
Out with the priests and let them live on their fat!





Everything I do, say, think, excrete, secrete, exude, ooze, or write 2007 Sweet Old Boo, Inc.

 


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