New recommendation to begin treatment immediately

[buginme2]

New York City health department released today that they now recommend beginning HIV treatment as soon as you are diagnosed regardless of CD4 counts, etc.

Here is an interesting quote from the article:

"The New York City health department is a little bit ahead of the curve," said Dr. Michael Saag, AIDS researcher at the University of Alabama at Birmingham and past chairman of the HIV Medicine Association. "In my opinion, the rest of the country will follow and I think it will be pretty quick."

"It's an anachronism. It's old school. It's yesterday," he said, of the standard measure of the CD4 count as a way to determine the strength of the immune system. "I agree completely with the New York City health department."

Link:

http://www.cbsnews.com/8301-504763_162-57334626-10391704/hiv-patients-need-aids-drugs-immediately-nyc-recommends/

[John2038]

F-I-N-A-L-L-Y !! *applauses*

[Miss Philicia]

That's great and all, but it doesn't address the 20% that don't know that they're infected, or of even greater concern, the 72% that know they're infected but don't adhere to treatment and are thus not having an undetectable viral load. linky

I think we often forget that this forum isn't very representative of the poz community, it's just a slice, and a slice of people that are fairly adherent with their treatment. There are huge slices of the pie that are urban or rural poor, and don't have a stable enough life to deal with treatment regularly, etc. Also higher levels of alcohol and drug abuse with accompanying depression, much of this simply isn't addressed effectively.

[buginme2]

That's great and all, but it doesn't address the 20% that don't know that they're infected, or of even greater concern, the 72% that know they're infected but don't adhere to treatment and are thus not having an undetectable viral load. linky

I think we often forget that this forum isn't very representative of the poz community, it's just a slice, and a slice of people that are fairly adherent with their treatment. There are huge slices of the pie that are urban or rural poor, and don't have a stable enough life to deal with treatment regularly, etc. Also higher levels of alcohol and drug abuse with accompanying depression, much of this simply isn't addressed effectively.

Absolutely, and that statistic that 28% of HIV pos people in the US have an undetectable viral load and as many as 50% of those who know they are positive do not even see the doctor on a regular basis is...shocking to me and horrible from a public health measure.

That said, even though treating everyone may not be practical or even possible.  I'm under the opinion that public policy should be of the theory of what we want it to be (treat everyone) understanding that, the reality may fall short.  We should always be working towards that goal though.   

[jkinatl2]

That's great and all, but it doesn't address the 20% that don't know that they're infected, or of even greater concern, the 72% that know they're infected but don't adhere to treatment and are thus not having an undetectable viral load. linky

I think we often forget that this forum isn't very representative of the poz community, it's just a slice, and a slice of people that are fairly adherent with their treatment. There are huge slices of the pie that are urban or rural poor, and don't have a stable enough life to deal with treatment regularly, etc. Also higher levels of alcohol and drug abuse with accompanying depression, much of this simply isn't addressed effectively.

I like to think I help skew the forum stats closer to reality with my stunning lack of adherence to medications.

[Valmont]

Very interesting...

Here I don´t have access to any treatment till my CD4 get under 500 in the best of the case.

Is there some place it is possible to access to treatment regardless to CD4 count?

[Since2005]

New York City health department released today that they now recommend beginning HIV treatment as soon as you are diagnosed regardless of CD4 counts, etc.

Yada Yada yada!!!!  Drugs/treatment should be based on individual evaluations of risk and benefit.. etc..

I hope they did talk about short and long-term side effects for starting treatments and also for lack of adherence developing drug resistance issues..

Give me a break and yaa if you respond to this.. save the denialist crap for someone else!

Another CDC crap!!!!!

Since2005
(Who really liked Sean Strub’s comments “While the newer drugs and regimens are more effective and generally less toxic than the worst of the old ones, many people will still develop very serious side effects from therapy, including many people who are just commencing therapy today.  We know more about these side effects than ever before, but there is an ocean of knowledge we don't yet have and it is clear that there are side effects that don't show up for years and years, decades even, after one commences therapy” or this one – “The most successful survivors, in my experience, are those who become very well-informed, remain skeptical and are constantly listening to and learning from others who have HIV. “


N.B. I am not advocating delaying meds in general. Just saying in advance
 I am not here to argue I have just voiced my opinion and I always will whatever that I believe in.

[John2038]

Very interesting...

Here I don´t have access to any treatment till my CD4 get under 500 in the best of the case.

Is there some place it is possible to access to treatment regardless to CD4 count?

In South Africa, 1 months Atripla, sold in 2 pills (Stocrin/Truvada) cost 90USD at the phamacy.
You will need a prescription from RSA doc (~30USD), and can buy months supply. 

Cheers
John

[spacebarsux]

What's the hell is the point in waiting for the START Clinical Study results that are to conclusively determine whether there is a 'net benefit' in commencing therapy with counts >500 ?  

All these clinics seem pretty convinced that early therapy is the best course for some reason or the other,regardless of conculsive proof from the START clinical study results.

Is there a single 'non-US' clinic that has also adopted this 'test and treat' approach? If so, where?

[bufguy]

I tend to agree with Doctors that are recommending that any HIV+ person start treatment right away.
Let's face it very few people will be elite contollers or long term non progressors which means that without meds their CD4 will continue to fall. There is also mounting evidence that people that stay undetectable and maintain high CD4 counts keep inflammation to a minimum and are less likely to develop cardio problems, cancers and other maladies.
Medications have improved significantly too. Although they still have side effects and long damage is still unknown, it is much better than 10-15 years ago and they are certainly easier to take...in many cases 1 pill per day. A track record is being developed.
My point is that if meds are inevitable for the vast amount of people eventually, why wait? What is 5 years out of 50 years for a young person.

[buginme2]

What's the hell is the point in waiting for the START Clinical Study

Is there a single 'non-US' clinic that has also adopted this 'test and treat' approach? If so, where?

Its done from a public health standpoint.  If you reduce an entire communities viral load you will reduce the overall number of cases of HIV ie people dont spread HIV if they are undetectable.  The start study is looking at the health of the specific patient, two different issue.

Yes, Vancouver BC Canada was the first (that I am aware of) to push for/advocate universal treatment.  

This is already the policy in San Francisco.

[Valmont]

In South Africa, 1 months Atripla, sold in 2 pills (Stocrin/Truvada) cost 90USD at the phamacy.
You will need a prescription from RSA doc (~30USD), and can buy months supply. 

Cheers
John

And it is easy to travel with this?  To buy them? To keep them well conservated?  It is avalable in the whole country that way?

I won´t be afraid to do this travel for medecines... and affording to know a probably very interesting country...  For curiosity (I´m not yet on med), in Brasil is it possible to find this king of offer?

[LM]

Despite possible benefits, I see this move of great interest for pharmaceutical companies. I don't doubt there is a lobby behind this, so I'm very skeptical to the real motives.

For curiosity (I´m not yet on med), in Brasil is it possible to find this king of offer?

No, it's illegal to sell HIV meds in Brazil, since the government provides them for free. No Atripla, though.

[Inchlingblue]

I wonder if the great city of NY will be supplying free meds to those without health insurance who test poz.

[Valmont]

No, it's illegal to sell HIV meds in Brazil, since the government provides them for free. No Atripla, though.

It is exactly the same in Ecuador...  Don´t thing it is so bad to forbidd to sell the meds if the State gives them to you for free, unfortunatelly, they are not last one on the market, but so lucky to have a great treatment almost for free.

(Change of language from spanish and complete the idea...)

[mecch]

Very interesting...

Here I don´t have access to any treatment till my CD4 get under 500 in the best of the case.

Is there some place it is possible to access to treatment regardless to CD4 count?

In Switzerland there are treatment protocals. But its understood in Geneva doctors are generally "treat when diagnosed".  And anywhere, if you request to start, you can, no matter your numbers.

[spacebarsux]

Its done from a public health standpoint.  If you reduce an entire communities viral load you will reduce the overall number of cases of HIV ie people dont spread HIV if they are undetectable.  The start study is looking at the health of the specific patient, two different issue.

I tend to agree with Sean Strub's views on this:

"5. ART for HIV-positive partners with ≥350 CD4 cells/μL in serodiscordant couples is recommended to reduce HIV transmission to uninfected partners. Strong recommendation, high quality evidence.

This explicitly prioritizes a public health objective over the health of the individual person with HIV.  It does not reference the very real possibility, if not likelihood, that treatment for some people >350 CD4 cells may harm them.  

It has not yet been demonstrated conclusively that, on average, those with >350 CD4 cells will receive a net benefit from anti-retroviral therapy.  The START trial or other research may demonstrate that is the case, but it might also prove that there is more net harm than benefit.  

Until we have that research, to recommend such treatment to patients under the guise of it being in their own personal best interest, or in the absence of a very clear informed consent procedure with appropriate recognition of the potential harm, is medical experimentation, at best.  Advising patients that such treatment can render them nearly non-infectious is appropriate, but they should also be advised of the potential risks to their own health. "

Source: http://blogs.poz.com/sean/

[mecch]

Yada Yada yada!!!!  Drugs/treatment should be based on individual evaluations of risk and benefit.. etc..

I hope they did talk about short and long-term side effects for starting treatments and also for lack of adherence developing drug resistance issues..

Give me a break and yaa if you respond to this.. save the denialist crap for someone else!

Another CDC crap!!!!!

Since2005

Dearie we don't have to restrain ourselves: You had your head in the sand out of fear and I'd say you've made a lot of progress but you still got some sand in your eyes and ears.

It's not "yada yada".  Treatment at diagnosis is a huge commitment to patients and to public health. There are arguments for and against but its not some reckless project that you should be dismissing.

[Tim Horn]

I wonder if the great city of NY will be supplying free meds to those without health insurance who test poz.

Those who don't have insurance and don't qualify for either Medicaid or Medicare can get meds through New York's (still relatively generous) ADAP program.

However...

For a lot of disenfranchised people living with HIV in New York, access to housing, case management, clinic transportation and nutritional programs is a must -- and there's no shortage of evidence that each of these are necessary when the goal is excellent ARV treatment adherence. The problem is, many people can only access these supportive programs upon qualifying for HIV/AIDS Services Administration benefits... which, at present, are only available to those with no more than 200 CD4s.

So, while the Department of Health and Mental Hygiene is now recommending treatment for all people living with HIV, regardless of CD4 cell counts, it's now up to Bloomberg and New York City Council to meet these recommendations with increased funding for supportive services. This will ultimately be a very tough fight, given that Guiliani and Bloomberg have repeatedly voiced desires to cut HASA funding, not increase it.

Tim

[madbrain]

Very interesting...

Here I don´t have access to any treatment till my CD4 get under 500 in the best of the case.

Is there some place it is possible to access to treatment regardless to CD4 count?

That choice was certainly offered to me at Kaiser in Northern California very early on after diagnosis. But the doctor recommended to wait based on my lab results. I listened.

[Inchlingblue]

Those who don't have insurance and don't qualify for either Medicaid or Medicare can get meds through New York's (still relatively generous) ADAP program.

 

I don't think it's that simple, Tim. ADAP in New York has income restrictions and assets restrictions. If I lost my job (hence, also lost my insurance) because I have over $25K in the bank (which I believe is the highest amount allowable in assets for ADAP in NY State) I would not qualify. I guess after COBRA were to run out, I could spend the money on meds and lab tests and doctor's visits until it got below $25K and then I could get ADAP. Woohoo.

Basically if I want to qualify for ADAP I can't ever aspire to having more than $25K in the bank.

God forbid we should have a nest egg/any retirement savings.

[denb45]

Basically if I want to qualify for ADAP I can't ever aspire to having more than $25K in the bank.

God forbid we should have a nest egg/any retirement savings.

Yes unfortunately this is the way it is in all States, do what I do and buy a fireproof safe, no one can really ding ya, for what they don't know you have, especially if they have no proof ........just sayin 

[Miss Philicia]

I don't think it's that simple, Tim. ADAP in New York has income restrictions and assets restrictions. If I lost my job (hence, also lost my insurance) because I have over $25K in the bank (which I believe is the highest amount allowable in assets for ADAP in NY State) I would not qualify. I guess after COBRA were to run out, I could spend the money on meds and lab tests and doctor's visits until it got below $25K and then I could get ADAP. Woohoo.

Basically if I want to qualify for ADAP I can't ever aspire to having more than $25K in the bank.

God forbid we should have a nest egg/any retirement savings.

liquid assets, moneybags... figure out a way not to make it liquid. Put it in a retirement account or some such scheme (or better yet get a financial advisor).

[madbrain]

Yes unfortunately this is the way it is in all States, do what I do and buy a fireproof safe, no one can really ding ya, for what they don't know you have, especially if they have no proof ........just sayin 

No, that is not true for all states. The maximum asset requirement does not exist for ADAP in California.

[denb45]

No, that is not true for all states. The maximum asset requirement does not exist for ADAP in California.

Your Probably right, I was on ADAP after my cobra run out w/ kaiser back in 97, and I'm not really sure what they do now, as I haven't lived in nor-cal for the last 9yrs. I do know that they have changed some things as far as FPL go's w/ Medi-cal, but I'm not sure what that even is now 

[zorro62]

So what about the other surveys I saw recently and that were discussed on this forum that compared
1) the life expectancy of people who started meds with cd4 account above 500
2) the life expectancy of people who started meds with cd4 count b/w 350 and 500

and found no difference...In essence saying there was no value to starting meds when cd4 was greater than 500?
Are the New York Doctors ignoring these studies?

Here is the link to the study:
http://www.aidsbeacon.com/news/2011/09/26/starting-antiretroviral-therapy-early-does-not-reduce-the-risk-of-aids-or-death/


@madbrain. Is there a single repository of info that explains the rules each state has for allowing someone to qualify for ADAP. Could you, for example, own your own house but show little savings and still qualify?
In Texas here.

[madbrain]

zorro62,

@madbrain. Is there a single repository of info that explains the rules each state has for allowing someone to qualify for ADAP. Could you, for example, own your own house but show little savings and still qualify?
In Texas here.

I am not aware of a nationwide resource. I think you have to look at your state's web site, since the plans vary by state.
I believe this is the one to look at for Texas :
http://www.dshs.state.tx.us/hivstd/meds/default.shtm

[Since2005]

There isn't any room for discussion for early treatment who would be suggested to start meds for someone like Madbrain's stat (member before me in this thread) in 2006. Someone like him in 2006 was over 650+ CD4 count and other stat being high and be recommended to start meds is yadda yadda and yes another CDC crap!

[madbrain]

Since2005,

There isn't any room for discussion for early treatment who would be suggested to start meds for someone like Madbrain's stat (member before me in this thread) in 2006. Someone like him in 2006 was over 650+ CD4 count and other stat being high and be recommended to start meds is yadda yadda and yes another CDC crap!

I have no idea what you mean by "yadda yadda". But for the record, the reason I started meds was not due to my stats, which were excellent. I was even in controller studies. However, I had terrible fatigue. Going on the drugs definitely helped with that. I waited 3 years before making that decision, and I am sorry I did.

[bocker3]

There isn't any room for discussion for early treatment who would be suggested to start meds for someone like Madbrain's stat (member before me in this thread) in 2006. Someone like him in 2006 was over 650+ CD4 count and other stat being high and be recommended to start meds is yadda yadda and yes another CDC crap!

What the hell is wrong with you?  It's one thing to disagree with a recommendation, but it's something else entirely when you start trying to use someone else's history to disparage a recommendation.  What you believe and what Madbrain did have nothing at all to do with each other.

We get it -- you don't like the recommendations, you don't want ANYONE to debate it with you, so if that is really what you want, you've stated your thoughts - now shut the hell up about it.  Or..... retract your comment about not wanting to discuss it, seeing as you can't seem to stop -- you can't have a one sided debate.

Mike

edited to add:
of course, I could give a rat's ass about what you think around recommendations of doctors and scientists.  You are entitled to your opinioin, though.

[Since2005]

What the hell is wrong with you?  It's one thing to disagree with a recommendation, but it's something else entirely when you start trying to use someone else's history to disparage a recommendation.  What you believe and what Madbrain did have nothing at all to do with each other.

We get it -- you don't like the recommendations, you don't want ANYONE to debate it with you, so if that is really what you want, you've stated your thoughts - now shut the hell up about it.  Or..... retract your comment about not wanting to discuss it, seeing as you can't seem to stop -- you can't have a one sided debate.

Mike

edited to add:
of course, I could give a rat's ass about what you think around recommendations of doctors and scientists.  You are entitled to your opinioin, though.

I will just gently respond to this-

I was replying to Meech. Madbrain's was (whose CD4 was 650+ at the of diagonsis , I could have used mine but I just didnt know my number then ). He was fine for number of years without meds and so am I. He and I are living reasons why this recommendation is bull crap! What a waste of resources !

You are damn right l am entitled to my opinion. I already have stated the reasons.

Since2005
(Who once was advised by a wise man in this forums not to respond in kind!)

[mecch]

I was replying to Meech. Madbrain's was (whose CD4 was 650+ at the of diagonsis , I could have used mine but I just didnt know my number then ). He was fine for number of years without meds and so am I. He and I are living reasons why this recommendation is bull crap! What a waste of resources !

Since2005 - Madbrain was NOT fine, he had no energy.  If you are fine, that's cool. There are plenty of people who do well for years with HIV and no treatment.  Noboday is saying those people don't exist.  Look at Ann for example.

A group of doctors or a city or state or a country's health authorities recommending HAART at diagnosis regardless of numbers or years - just means they decided there may be advantages personally or to public health.

Its not "bull crap".  Its a sea change in medical community opinion AND in public health policy.  It's not saying you or anyone else can't go on monitoring and waiting for the moment that is right for you.  Its saying that the science says its OK to treat at diagnosis, and that the government and insurance needs to find the funds to make this happen.  

Why do you consider this bull crap???

[leatherman]

@zorro62

I am not aware of a nationwide resource. I think you have to look at your state's web site, since the plans vary by state.

I don't think there's a national resource laying out all the issues as they change yearly based on state budgeting and state requirments. Looking at the NASTAD report (http://www.nastad.org/) is a partial list of some cost containment measures and Kaiser (http://statehealthfacts.org/comparetable.jsp?ind=551&cat=11) lists some of the formulary differences. but the only way to truly know is to look at each state's information on their health department's website.

anyone on ADAP thinking of moving should always check out this information while in the planning stages of their move.

God forbid we should have a nest egg/any retirement savings.

anyone already receiving assistance can tell you that getting state/federal assistance for health issues often requirements people to have very limited or zero personal resources.

[newt]

This whole idea only works if you have the financing in place for everyone, address basic needs/addiction issues that compromise adherence and the end users buy the arguments on benefit of immediate treatment. Plus a huge proportion of transmissions in eg the UK, British Columbia come from people who don't know they are HIV-positive and I guess it ain't different in NY, so you also need a decent testing strategy if you are after a public health effect (including reducing expensive emergency hospital admissions for very ill, undiagnosed people with AIDS). Otherwise you might as well piss off the Brooklyn Bridge on a windy day.

Personally, if diagnosed now, knowing what I know now, I would go on treatment straight away. But when I was diagnosed I knew jack shit and wanted to defer meds for as long as possible.

- matt

[bocker3]

I will just gently respond to this-

I was replying to Meech. Madbrain's was (whose CD4 was 650+ at the of diagonsis , I could have used mine but I just didnt know my number then ). He was fine for number of years without meds and so am I. He and I are living reasons why this recommendation is bull crap! What a waste of resources !

You are damn right l am entitled to my opinion. I already have stated the reasons.

Since2005
(Who once was advised by a wise man in this forums not to respond in kind!)

So, are you unable to read??  Madbrain clearly stated that he was not fine, he started meds for a reason, so he is NOT an living reason why this recommendation is "bull crap".  It is perfectly fine to have an opinion -- however it is not fine to twist the words or situations of others to try and make them fit your view - that is what one would call BULL CRAP.

If I were you (and thank god I am not....) I would look at just why this recommendation has hit such a nerve in you.  A recommendation is nothing more than just that -- it's not a mandate, it is not a promise, it is simply a recommendation.  Hell, if you asked the folks who issued it, they'd probably agree that there are a host of reasons why any particular individual might not be best served to follow it.

Mike

[Since2005]

@Madbrain, I am sorry that I skipped your reply before I replied mine. I am totally with u. As I understand u had good stats , u waited few years and with your doc recommendation u started meds and u are fine. As I have indicated treatment should be based on individual risks and evaluations. If u have to be on it , then u have to be on it. I,myself, getting there. I don't feel the way u do. I am skeptical about side effects. No, I am not talking about known short-term side effects. I am talking about long-term side effects that no one is aware of, even the doctors. For Atripla, they mentioned on their website as they are aware of only 3 years long term side effects. I'm very fond of Sean's attitudes towards this ( my first reply to this thread). HIV meds are so new and unknown and even docs and researchers do not know what effects these meds going  to have on us in the long run. If I could avoid taking the meds, why wouldn't I?

@Meech - Newt made a very good point about the resources. Now what's gonna happen is people are gonna be taking meds who could have waited, making others who really needs it, wait on list. My main concern is not that. Let's say City has enough resources to put people in meds , but what they neglect to tell people is about not known side effects which is years to come. We know lots of those now but there is a ocean knowledge we still don't know about which may show up 5/10/15 years later.
 
If u talk about public health, do u know how many people in NYC don't know/ don't want to test for HIV. People who know their status, are not the main problem. They actually are more educated and more protective of others.

Please read my first reply including Sean's comments, then 'hopefully' u will get to understand. CDC is not looking out for Poz people or any other certain individuals, as they never have ( website is the living proof). I am afraid this decision is made to look out for mass, possibly lobbyed by certain interest groups, not based on individual needs. Any treatment recommendations should be based on individual evaluations, if it is suggested otherwise, is a big bull crap to me.

Since2005

Edited to correct spelling etc.

[spacebarsux]

Personally, if diagnosed now, knowing what I know now, I would go on treatment straight away. But when I was diagnosed I knew jack shit and wanted to defer meds for as long as possible.

- matt

Hi Matt,

I greatly respect your knowledge on HIV disease and treatment. Can I request you to briefly explain why you would go on treatment straight away?

Do you think it unnecessary to wait for conclusive proof from the START clinical results confirming if there is a net-benefit in commencing therapy ASAP ?

If the benefit of early treatment outweighs the negatives so significantly, why is it that the WHO guidelines, the European Guidelines, the guidelines in all Asian countries tell us to wait until CD4 drops to 350 ? Are there some financial considerations in delaying treatment ? Or is it that policy makers are being overly cautious ?

PS:- I don't mean to be tedious. I am genuinely interested in hearing your thoughts.

Many thanks.

[bocker3]

I am talking about long-term side effects that no one is aware of, even the doctors. For Atripla, they mentioned on their website as they are aware of only 3 years long term side effects.

This seems just plain wrong or, more likely, very out of date.  Many people have been on the components of Atripla for far more than 3 years.  I've been taking Atripla or its precursors for 6 years now and I know others who have been on them much longer than I.  Perhaps you'll see more on the individual drug pages.

Any treatment recommendations should be based on individual evaluations, if it is suggested otherwise, is a big bull crap to me.

That is true for an individual's recommendations from his/her doctor.  When a public health entity makes recommendations it is for populations, as they don't have the ability to examine everyone.  As I pointed out earlier, and you ignored -- a recommendation is JUST THAT -- it isn't a mandate, it isn't even meant to imply that everyone, without exception, should follow it.

Being skeptical is healthy, being so paranoid about your own situation that you can't accept that something different than your thoughts could be good for many is not so healthy.

Mike

[buginme2]

There was recently a study published (out of Denmark I think) that said that long term use of antiretrovirals does not reduce life expectancy or increase the risk of non aids deaths cause by cardivascular disease, liver disease, or kidney disease.  

However, untreated HIV surely does.

PS Sean Strub is not some HIV messiah know all.   I'd prefer to get my medication advice from the medical community.  Study after study shows the benefit of HAART not to mention the one that shows those who are on medication and undetectable are 96% less likely to transmit.  From a public health perspective thats huge.  

If you want to argue facts go ahead, but don't call the recommendations crap or a consperacy.  It just shows your ignorance.

[Inchlingblue]

This whole idea only works if you have the financing in place for everyone, address basic needs/addiction issues that compromise adherence and the end users buy the arguments on benefit of immediate treatment. Plus a huge proportion of transmissions in eg the UK, British Columbia come from people who don't know they are HIV-positive and I guess it ain't different in NY, so you also need a decent testing strategy if you are after a public health effect (including reducing expensive emergency hospital admissions for very ill, undiagnosed people with AIDS). Otherwise you might as well piss off the Brooklyn Bridge on a windy day.

Personally, if diagnosed now, knowing what I know now, I would go on treatment straight away. But when I was diagnosed I knew jack shit and wanted to defer meds for as long as possible.

- matt

Wise words. Especially the part about having the financing in place for everyone, which is why I brought it up, above, whether NYC is prepared to supply meds to anyone and everyone who needs it, without the person having to jump through hoops and hide assets, etc.

Even those who do qualify for ADAP have to be re-applying (I think yearly) and filling out forms and proving they qualify, yada yada yada.

It should not be that hard but it is what it is, alas.

[bocker3]

Having a recommendation should not require funding or, conversly, having inadequate funding should not stop making recommendations.  There are plenty of "recommendations" out there for public health that aren't funded.  For instance, it is recommended that we all eat 5 servings of fruits and vegetables every day, but no one is providing the produce.  I simply don't get arguments like, don't recommend treatment if you won't pay for it. 

The fact that health care is not available to all in this country is a big problem and I wish it weren't so, however I wouldn't say that we should hold back on making recommendations because of it.

Mike

[Basquo]

Suppose this was the norm...they would still want to draw two sets of labs to get a baseline, right? Unless a patient was critically ill? How do they define "right away"? How would they determine if a person was a long-term non-progressor, or would that be of any concern? Seems like it would be a waste of money if the person didn't need the drugs, but apparently they don't want them to go ten years to see if they are still holding steady. I've yet to be convinced that the benefits outweigh the risks when you don't need the drugs.

However, and this is directed at Since2005, for the majority of HIV-positive persons, the benefits of HAART outweigh the risks. You've typed about side effects that doctors don't even know about; well, how is it that YOU know about them? What are they? Why do you say this is CDC crap when they aren't mentioned except as a resource for more general information on HIV/AIDS, at the end? And finally, do you or do you not agree that a risk of side effects is preferable to DEATH? Because for the majority of HIV-positive persons, no treatment = guaranteed death from the disease.

I've read the article but I can't find anything directly from the NY Health Dept. I wonder if CBS left anything out.

[Inchlingblue]

Having a recommendation should not require funding or, conversly, having inadequate funding should not stop making recommendations.  There are plenty of "recommendations" out there for public health that aren't funded.  For instance, it is recommended that we all eat 5 servings of fruits and vegetables every day, but no one is providing the produce.  I simply don't get arguments like, don't recommend treatment if you won't pay for it. 

The fact that health care is not available to all in this country is a big problem and I wish it weren't so, however I wouldn't say that we should hold back on making recommendations because of it.

Mike

I don't buy that. Not with HIV/AIDS. The whole point of test and treat is to "end" AIDS. That's a tall order and yet reachable if everyone who is poz were on meds. 

[bocker3]

I don't buy that. Not with HIV/AIDS. The whole point of test and treat is to "end" AIDS. That's a tall order and yet reachable if everyone who is poz were on meds. 

What, exactly, aren't you buying?  Why would HIV/AIDS be different from any other condition?  Could it be that HIV/AIDS is different in your mind because you have it?  Everyone thinks that "their" issue is somehow more important or worthy than others -- I get that, but the truth rarely matches up to that emotional attachment.

My point is that making a recommendation, from a public health perspective, does not require funding.  Yes, the recommendation may not be able to be followed by all without it -- but it doesn't lessen the truth about the recommendation.  Recommendations and funding ARE SEPARATE THINGS -- would be great if they could fund it, but it is still a solid recommendation anyway.

I agree that we could end this if everyone was treated -- of course, that would be everyone -- not just residents of NYC or the US. 

Mike

[Since2005]

Suppose this was the norm...they would still want to draw two sets of labs to get a baseline, right? Unless a patient was critically ill? How do they define "right away"? How would they determine if a person was a long-term non-progressor, or would that be of any concern? Seems like it would be a waste of money if the person didn't need the drugs, but apparently they don't want them to go ten years to see if they are still holding steady. I've yet to be convinced that the benefits outweigh the risks when you don't need the drugs.

However, and this is directed at Since2005, for the majority of HIV-positive persons, the benefits of HAART outweigh the risks. You've typed about side effects that doctors don't even know about; well, how is it that YOU know about them? What are they? Why do you say this is CDC crap when they aren't mentioned except as a resource for more general information on HIV/AIDS, at the end? And finally, do you or do you not agree that a risk of side effects is preferable to DEATH? Because for the majority of HIV-positive persons, no treatment = guaranteed death from the disease.

I've read the article but I can't find anything directly from the NY Health Dept. I wonder if CBS left anything out.

Agreed 100% on the first para.
For second para, can u give one single reason why did u direct that at me? I did not give any indications of anything that u said.
Hint. Please read my answer @ Madbrain and other replies. If u still don't get your answers let me know.
Another hint - We are NOT talking about no treatment options unless u got confused with Bugin's answer.
Double hint - we are talking about unknown long term side effects of meds, Pharma put as a warning to be truthful.
Last but not the least - did u read the whole thread? Then u would know I am considering treatment options for myself in the near future to outweigh the risks and save my life because by then I will be making an educated decision. I would need the meds by then. Just so that we are clear, we are talking about a recommendation  (pretty crappy one) where they recommend for people to go on meds even when they don't need it.
BTW, u do know CDC is more than a HIV and AIDS information resource center, right?

I think you are a good man Basquo but look what u made me do- repeat myself. But, you did make a very good point - This recommendation encourages waste of resources!

@ Bugin - Please don't twist words and confuse people.  It shows ignorance when one is pretty darn sure about side effects that meds offer in exchange of saving lives and act pretty ignorant about it! Studies after studies shows people suffer from heart attacks, liver disease, kidney problems,etc. for using meds along with some unknown side effects in the long run!  Some of us don't have any choice (as I said I may be one of them soon) but the ones can they shouldn't be encouraged unnecessarily (Unnecessarily is the key word).

Since ( Who has learned to differ between noise and discussion and always up for discussion not for the noise)

Edited to add : I hate to think that the policymakers and doctors think us poz people fucking everything that we can and the only way they could stop us is make the virus UD?? Really???

[buginme2]

Exactly what words am I twisting?  I stated there was a recen study that said there was not a risk of non AIDS related deaths due to long term antiviral use.  

Here is a link to that story:

http://www.thebody.com/content/65100/study-finds-that-long-term-use-of-hiv-drugs-doesnt.html

Oh, and I said - just because Sean Strub says something doesnt mean its true.  Hes a blogger, not a scientist.  He has a right to his opinion but do your own research and make your own decisions, and that I would rather get my advice from doctors than some blogger (ya I can see how thats twisted). 

[denb45]

What's the matter with all you dam queers? I've been on HIV/MEDS for the last 22 yrs. I took them cause back then that was all they had, and I'm still on them, take the dam MEDS, and feel better ,ok, I'm out

[Basquo]

Agreed 100% on the first para.
For second para, can u give one single reason why did u direct that at me? I did not give any indications of anything that u said.
Hint. Please read my answer @ Madbrain and other replies. If u still don't get your answers let me know.
Another hint - We are NOT talking about no treatment options unless u got confused with Bugin's answer.
Double hint - we are talking about unknown long term side effects of meds, Pharma put as a warning to be truthful.
Last but not the least - did u read the whole thread? Then u would know I am considering treatment options for myself in the near future to outweigh the risks and save my life because by then I will be making an educated decision. I would need the meds by then. Just so that we are clear, we are talking about a recommendation  (pretty crappy one) where they recommend for people to go on meds even when they don't need it.
BTW, u do know CDC is more than a HIV and AIDS information resource center, right?

I think you are a good man Basquo but look what u made me do- repeat myself. But, you did make a very good point - This recommendation encourages waste of resources!

@ Bugin - Please don't twist words and confuse people.  It shows ignorance when one is pretty darn sure about side effects that meds offer in exchange of saving lives and act pretty ignorant about it! Studies after studies shows people suffer from heart attacks, liver disease, kidney problems,etc. for using meds along with some unknown side effects in the long run!  Some of us don't have any choice (as I said I may be one of them soon) but the ones can they shouldn't be encouraged unnecessarily (Unnecessarily is the key word).

Since ( Who has learned to differ between noise and discussion and always up for discussion not for the noise)

Edited to add : I hate to think that the policymakers and doctors think us poz people fucking everything that we can and the only way they could stop us is make the virus UD?? Really???

You said "CDC crap" and "long-term side effects that no one is aware of, even the doctors" and when I read that it overshadowed everything else you said previously, and yes, I did read the entire thread. You also said something to the effect that the CDC is not on the side of poz people and while that may be construed by examining their policies and procedures and actions, they do have thebody.com which is directed at poz people and they're not telling people about side effects that they can't name and haven't manifested and have no proof of. When these phantom side effects do show up in a few decades please feel free to tell me "I told you so" but until then you need to be taken down a notch. Your words have the potential to scare people into not taking the medication that they need and that is deadly.

[buginme2]

Edited to add : I hate to think that the policymakers and doctors think us poz people fucking everything that we can and the only way they could stop us is make the virus UD?? Really???

Um, there are over thirty million people with HIV and just as many people have died.  So, Ya policy makers are trying to do more than just say "wear a condom" as that hasn't work.  If this somehow offends your delicate feelings you need to get over it.   As mentioned many times an undetectable viral load reduces transmission by 96%. 

Source for HIV statistics
http://www.avert.org/worldstats.htm

[leatherman]

Just so that we are clear, we are talking about a recommendation  (pretty crappy one) where they recommend for people to go on meds even when they don't need it.

one thing to consider is the phrase you used "even when they don't need it". Eventually everyone with HIV will need HAART. Every day even LTNPs edge ever more closer to the point of needing HAART. HIV, unchecked/untreated always "wins" in the end. So all this is just quibbling about the best starting point of meds, not the idea of starting meds when they aren't needed.

It shows ignorance when one is pretty darn sure about side effects that meds offer in exchange of saving lives and act pretty ignorant about it! Studies after studies shows people suffer from heart attacks, liver disease, kidney problems,etc. for using meds along with some unknown side effects in the long run!

the studies do NOT show that everyone, much less the majority of patients, end up with these side effects. Check out those studies - really consider the numbers/percentages of who experiences what side effects. Although cases of heart attack, liver disease, etc are elevated in those with HIV and/or on HAART (the jury is often still out on whether these problems are from the disease or the meds), these issues do NOT strike everyone by any stretch of the imagination. While 22% having liver disease is an issue of concern, it's a non-issue for 3/4ths of the people on those drugs.

And to be honest, although those issues are worth considering, consider the alternative. I would much rather die from a heart attack at 72 than from AIDS at 32. I was in a hospital quite possibly dying from AIDS/PCP when I was 32. Because of 19 yrs of HAART, from which I currently have no liver, heart, kidney etc related issues, I'm coming on 50 in the first part of the new year. If I were to die at 55 from a HAART-related side effects, the extra 20+ years would have been worth the trouble of HAART rather than having been dead back at 32.

Some of us don't have any choice (as I said I may be one of them soon) but the ones can they shouldn't be encouraged unnecessarily (Unnecessarily is the key word).

no HIV+ person has a choice. (well they do, but I don't encourage suicide ) In the end we will all have to be on HAART or risk dying from AIDS. About 1/3 of us had no choice from the very beginning as we were diagnosed with AIDS when we found out we were positive. We've never seen the meds in a bad light (no matter the side effects) because the meds represent the only life-saving, life-enhancing option. I've also known plenty of people in that other 2/3rds that didn't believe meds were bad either, so they started meds early enough to never experience any of the horror of having AIDS, so starting early is definitely not that bad of a thing.

[Since2005]

Um, there are over thirty million people with HIV and just as many people have died.  So, Ya policy makers are trying to do more than just say "wear a condom" as that hasn't work.  If this somehow offends your delicate feelings you need to get over it.   As mentioned many times an undetectable viral load reduces transmission by 96%.  

Source for HIV statistics
http://www.avert.org/worldstats.htm

I could see how being UD could make someone feel better / may be more effective when they are in poz and neg relationships. But that doesn't mean this will work to reduce the spread to the rest of the country. Do u have any idea how many people in nyc don't even test? As I said who actually know, they are protective of others. Without placing proper testing strategy, this won't work. Only NYC and SF, come on ? Please read Matt/Newt's respond on that.

The thought of putting people on meds when they don't need to be on it (due to side effects issues, resource problems, etc.) to reduce the spread is ridiculous.

Apparently, I can't talk about side effects even if its true ( Bug, I don't need to cite link like you, that would be too many of them, just google, it will come up. Yes, body.com is one of them. Basquo, known side effects are clearly mentioned to that cite).

Just so that we are clear on few things -

# I am not advocating to delay meds in general
# Meds outweigh the other risks when it comes down to saving lives
# This recommendation is crap aka bull because it encourages people to be on meds even when its NOT NECESSARY!

Edited to add - Leatherman, I saw you posted while I was writing. We are discussing a recommendation (per thread) , NOT the importance of taking meds. Please read my reply to Basquo.

Since2005 (who clearly needs...a) lesson to explain things better b) vodka tonic c) break d) damn good sex...or all of the above)

[mecch]

Since, you are an HIV+ person who had an opinion that there is no benefit from starting HAART before "necessary". 

However, there are many many doctors now who feel that there is a benefit to starting HAART, at diagnosis.  Even sometimes within months after seroconversion.  Some even see a benefit to starting at seroconversion.

DOCTORS.  D.O.C.T.O.R.S.

So we get your opinion.

[Since2005]

However, there are many many doctors now who feel that there is a benefit to starting HAART, at diagnosis.  Even sometimes within months after seroconversion.  Some even see a benefit to starting at seroconversion.
 

Meech, I am sure you have done your research. So, besides the nasty side effects and waste of resources (sorry can't help but repeat), what are the benefits to starting meds (after one test) at seroconversion???

[mecch]

I don't answer questions that contain propaganda and beliefs presented as fact.

"besides the nasty side effects and waste of resources".

Since you need to chill out and stop half-.assed "research" of "nasty side effects" which only serves to float your fears and denials.  Leatherman pointed out some good places to start.  You are so full of fear and anxiety you are only seeing a quarter the reality.

[Since2005]

I don't answer questions that contain propaganda and beliefs presented as fact.

"besides the nasty side effects and waste of resources".

Since you need to chill out and stop half-.assed "research" of "nasty side effects" which only serves to float your fears and denials.  Leatherman pointed out some good places to start.  You are so full of fear and anxiety you are only seeing a quarter the reality.

Good one Meech! You asked me a question, I answered. You thought those are my opinions. That's fine.
Now, I asked you a question about your thoughts... Or, you don't reciprocate

Please don't direct this to leatherman. We already know what leatherman thinks about that. Please don't tell me what or how I feel about it as we already know. Exclude me out...

Meech, I really want to know what are the benefits to starting meds as early as seroconversion??

[newt]

what are the benefits to starting meds (after one test) at seroconversion

Viral suppression stops the damage  to the body caused by viral replication, especially ongoing immune activation resulting in inflammation, loss of T cells and interference with function of other white blood cells, not to mention disturbance of lipid and glucose metabolisms and attack on your gut. This in a nub is why I would start treatment immediately. The virus is damaging your body regardless of CD4 count except for the lucky very few whose bodies can master the virus naturally. Given that the median CD4 count at point of, eg UK diagnosis, is around 360, it's a moot point, starting immediately here (over the pond). But I'd do it even if my CD4 count was, eg 900. Plus ARVs reduce your chance of passing on the virus significantly, and I like that. It's good for how other people feel about me and how I feel about myself.

Starting treatment in seroconversion...well, apart from some dangers, perhaps it helps your body get a handle on the virus. But I would not do this. I would wait till my body had balanced itself with the virus, then start treatment. It's uncommon to get diagnosed during seroconversion, and if you are real ill at this time the medicine is difficult and there maybe there are more important things going on, like getting your head round being HIV-positive.

But, important point, if I got my diagnosis now and knew nothing about the pathology of HIV (like when I got my diagnosis) I am sure I would disagree with posting here and want to wait. Because the story goes: meds is a little bit horrid and onerous. Not so true eh, this story? The data says that uncontrolled HIV is always worse than controlled HIV, even if, like with a CD4 count of 500 or more, a marginal one.

Having a higher (500+)CD4 count gives you more thinking time that's all, and maybe a chance to see if you are one of the small % who will last years without meds, if you judge that to be a good thing. But CD4 count is not everything. There is the virus to consider.

- matt

[eric48]

Hi,

I found this documented comment interesting on this issue:

http://www.thebody.com/content/64948/top-10-hiv-aids-related-clinical-developments-2011.html?getPage=4#viremia

Eric

[mecch]

Since, in the acute phase. YOU projected "after only one test".  Nobody says someone has to do this or ought to but there are doctors who are fine to go there.

It doesn't matter what we discuss with you, you have your opinion, fears, denials... and your blinders on about the reality of living with HIV --- where you only look at facts that support your fears.

You have been dancing around this thread and mostly off topic, because you haven't read what it is about, nor even what people are writing.  Its all about fear, for you.

[bocker3]

# This recommendation is crap aka bull because it encourages people to be on meds even when its NOT NECESSARY!

Look, I know you don't care for me and I suppose that I could have been less abrasive earlier in this thread I will attempt to be more gentle with you, but you keep ignoring one important FACT.

A recommendation is not stating that every single person has to do what is recommended. 
No one is saying that the recommendation wipes out the need for a doctor and patient to work together to decide what is best for that individual.
A recommendation is something stated for a "general population" (in this case, that population is positive folks) -- but is not geared toward any specific individual.  There may be a whole host of reasons why any recommendation would not by right for a specific person. That being said -- it doesn't mean that the recommendation is crap (wasn't it YOU who once got all twisted up because I called something you said was 'crap').
You, as an indvidual, do not have to agree with the recommendation.  You, as an individual, do not have to heed the recommendation.
So.....  the recommendation is, of course, negating your simplistic argument that some folks "don't need meds yet".  The recommendation is stating that THERE IS HEALTH BENEFITS TO BE HAD BY STARTING MEDS RIGHT AWAY.  Now, an individual may opt not to start for many reasons, but the benefits of starting would still exist.  You can't wish it away, or "crap" it away.

Hopefully, that all makes sense to you and you don't just consider it "noise" -- else I'll start to assume that your definition of "noise" is simply something that runs counter to your opinion.

Mike

[zorro62]

@madbrain n leatherman...thanks for the info on the ADAP policies. I think I will start a separate thread on this subject as its "hijacking" the original thread

As for the original thread, observing the opposing views, I think it boils down to each individual trying to justify the paths they have chosen to follow...start meds asap or wait. Bottom line, imho, is to diligently search for a dr you trust and believe in; someone who has vast experience in treating poz patients. Someone who participates actively in research and trials and who has treated large numbers of patients. Sometimes the dr needs to rely not only on lab results but on gut feeling based on treating patiients with similar symptoms and  reactions to different meds in the past.

I am fortunate to be in Dallas where there are a number of good dr options...not all are so lucky. I trust my dr 100%; (researched all the drs in town; how they operate their clinics; whether they publish papers, participate in trials etc and talked to their patients before I selected the one I am now being treated by).

Whether on meds or not, we are all helping each other by allowing the research community to monitor our progress; having everyone on meds may delay the breakthroughs that can come from monitoring how some people can control the virus naturally; having no-one on meds would seriously hamper the ability to refine the HAART threatments already out there...so I vote for the mixed bag right now..the best chance for vaccine/cure

[spacebarsux]

Thanks for your insights, Matt.

I guess a lot of us who are treatment naive with CD4 >500 tend to think that since we 'feel alright' we can go without meds for some more time before being 'tied down forever' to 'toxic albeit lifesaving pills'. That's how I feel (at a purely emotional level) and I've spoken with others who feel/felt likewise.

Moreover, currently, guidelines almost everywhere, reflect and reinforce that sentiment as well.

I do understand however, that it's a fair bet that chronic immune activation, HIV thriving in the Gut, inflammation, etc are potent enough concerns to commence therapy asap but I'll also admit that when one has a 'choice to defer' therapy- most people would opt to delay it mainly cos most of us find it hard to view HIV disease and particularly ART objectively and without a shred of any of the usual irrational/typical fears that accompany them.

When I was diagnosed I saw an old man with a huge belly and a buffalo hump at the clinic. I swore to myself I'd rather be dead than ever look like that. I've come a long way since then. I also soon realised how insensitive and idiotic my thoughts were at the time.

[Rockin]

When I was diagnosed I saw an old man with a huge belly and a buffalo hump at the clinic. I swore to myself I'd rather be dead than ever look like that. I've come a long way since then. I also soon realised how insensitive and idiotic my thoughts were at the time.

Oh my God what awful, demonic meds could possibly do that??

[Miss Philicia]

Oh my God what awful, demonic meds could possibly do that??

Meds that were used in the early/mid-90's which are either no longer on the market or not ever used in current regimens. Hence don't fuss about it and don't stare at people in fucking clinics that are suffering from the lingering effects of 2 decades ago, because it's ridiculously rude.

[denb45]

 , I mean, don't let any of this scare you, and don't be afraid of what you may look like after 2 decades, if this is what bothering you, AIDS anit for everyone, so don't worry too much about any of this, this disease certainly aint for the squeamish  

[Inchlingblue]

What, exactly, aren't you buying?  Why would HIV/AIDS be different from any other condition?  Could it be that HIV/AIDS is different in your mind because you have it?  Everyone thinks that "their" issue is somehow more important or worthy than others -- I get that, but the truth rarely matches up to that emotional attachment.

My point is that making a recommendation, from a public health perspective, does not require funding.  Yes, the recommendation may not be able to be followed by all without it -- but it doesn't lessen the truth about the recommendation.  Recommendations and funding ARE SEPARATE THINGS -- would be great if they could fund it, but it is still a solid recommendation anyway.

I agree that we could end this if everyone was treated -- of course, that would be everyone -- not just residents of NYC or the US.  

Mike

What I'm not "buying," for one thing, is what you're saying regarding how a "recommendation" should be interpreted.

The word "recommendation" in this context is not the same as, say, me recommending to you that you should look both ways before crossing the street.

If you can't see that, then we can agree to disagree.

[bocker3]

What I'm not "buying," for one thing, is what you're saying regarding how a "recommendation" should be interpreted.

The word "recommendation" in this context is not the same as, say, me recommending to you that you should look both ways before crossing the street.

If you can't see that, then we can agree to disagree.

Oh, I see -- so what is YOUR interpretation, as all you seem to say is that you don't "buy" mine, but say nothing of your own? 
A recommendation is not a mandate, else it would be called, I don't know -- a mandate.  There are many recommendations put out by Public Health officials -- I see nothing different about this one.  I mean, it is recommended that one should not smoke -- is the government paying for cessation?  It is recommended that women of a certain age get mammograms, that is not funded.  It is recommended that people get their BP, Chol, and lots of other things regularly checked -- that is not funded.  I am not talking about crossing the street -- which I've never seen a Public Health official state as an official recommendation.  So, if you disagree -- fine -- tell me your thoughts but don't insult me by equating what I'm saying with crossing the street.  I know you are more intelligent than that.

Yes -- it would be GREAT if there were funding for HIV treatment for all -- I hope someday we, as a nation, smarten up and get health care for all -- but today we don't.  Therefore -- recommendations and funding are separate issues in the USA.

Mike

[Inchlingblue]

Oh, I see -- so what is YOUR interpretation, as all you seem to say is that you don't "buy" mine, but say nothing of your own? 
A recommendation is not a mandate, else it would be called, I don't know -- a mandate.  There are many recommendations put out by Public Health officials -- I see nothing different about this one.  I mean, it is recommended that one should not smoke -- is the government paying for cessation?  It is recommended that women of a certain age get mammograms, that is not funded.  It is recommended that people get their BP, Chol, and lots of other things regularly checked -- that is not funded.  I am not talking about crossing the street -- which I've never seen a Public Health official state as an official recommendation.  So, if you disagree -- fine -- tell me your thoughts but don't insult me by equating what I'm saying with crossing the street.  I know you are more intelligent than that.

Yes -- it would be GREAT if there were funding for HIV treatment for all -- I hope someday we, as a nation, smarten up and get health care for all -- but today we don't.  Therefore -- recommendations and funding are separate issues in the USA.

Mike

When a recommendation regards a public health concern, in this case a sexually transmitted and deadly disease if left untreated, it needs to be backed up with funding or it's pointless. And not just funding but all of the other aspects of support that Newt so eloquently mentioned above.

The irony is that it would very likely be less expensive in the long run for governments to provide meds (ideally worldwide) if it meant halting rates of transmission and thereby eventually "ending AIDS." Something that seems statistically possible with "test and treat."

[Assurbanipal]

When a recommendation regards a public health concern, in this case a sexually transmitted and deadly disease if left untreated, it needs to be backed up with funding or it's pointless. And not just funding but all of the other aspects of support that Newt so eloquently mentioned above.

This ignores the fact that different parties recommend and fund.  The people who allocate funding are politicians.  Do you really think that politicians should be in charge of recommending when to start treatment?

It makes a lot more sense if first scientists and doctors make recommendations and then politicians evaluate funding in light of the recommendations, the quality of the recommenders and totality of needs and resources.

[bocker3]

When a recommendation regards a public health concern, in this case a sexually transmitted and deadly disease if left untreated, it needs to be backed up with funding or it's pointless. And not just funding but all of the other aspects of support that Newt so eloquently mentioned above.

The irony is that it would very likely be less expensive in the long run for governments to provide meds (ideally worldwide) if it meant halting rates of transmission and thereby eventually "ending AIDS." Something that seems statistically possible with "test and treat."

This may be how we would like it to be -- but I was speaking of our actual reality.  I agree with your "perfect world scenario", alas, we do not inhabit a perfect world.

Mike

[buginme2]

If we waited until any public policy change was completely funded before it was recommended we would have no policy changes. 

[TonyDewitt]

Lots of good points made in this thread:

(1) Starting drug therapy immediately is good for the patient (health wise) and good for the population (infectability wise). The attitude that waiting until you get sicker is a reasonable option always irked me. Please temper this with it is a free country and if you want to refuse to take medication that's your right.

(2) Anyone who started with an AIDS diagnosis wishes that they known sooner and had taken drug therapy sooner. Please temper this with what drugs were / were not available at the time and how toxic they may have been. We all agree that treatment today isn't anything like what it was 20 years ago.

I'll add my observation that whenever a government organization officially recognizes a need (such as immediate HIV medication), that usually translates into financial support for that need. Fortunately, NY & SF have the common sense and bravery to make it official, and eventually everyone else will too. Their statement is a lot closer to giving a crap about HIV folks than if they stated the opposite. And giving a crap is what we need everyone to do to get a handle on this epidemic.

[Inchlingblue]

This ignores the fact that different parties recommend and fund.  The people who allocate funding are politicians.  Do you really think that politicians should be in charge of recommending when to start treatment?

It makes a lot more sense if first scientists and doctors make recommendations and then politicians evaluate funding in light of the recommendations, the quality of the recommenders and totality of needs and resources.

There are already treatment guidelines in the US, devised by "panels of clinicians and researchers brought together by organizations including various U.S. government agencies, the American Medical Association, and the International AIDS Society - USA."

http://hivinsite.ucsf.edu/insite?page=md-01-01

In the case of HIV/AIDS, in my opinion there's enough evidence for NYC to "recommend" starting treatment upon diagnosis if it means, statistically, a stop to the pandemic. They just need to put their money where their mouth is or it's pointless.

[newt]

They just need to put their money where their mouth is or it's pointless.

Well said. Policy without finance is like the emperor's new suit, it delivers nothing.

- matt (lives in a socialised health benefit country, so igone) the newt

[bocker3]

In the case of HIV/AIDS, in my opinion there's enough evidence for NYC to "recommend" starting treatment upon diagnosis if it means, statistically, a stop to the pandemic. They just need to put their money where their mouth is or it's pointless.

It isn't "pointless" to the majority of folks who do have access to healthcare.  Withholding a proper recommendation because there isn't funding for everyone is ridiculous.  While, I AGREE, funding it would be ideal, the lack of funding does not remove the fact that it is good for you.

You are confusing two issues here....  plain and simple.  Again, it would be ideal to have both, but not having one doesn't negate the other.  The "all or nothing" approach is why nothing is happening in DC.  Everyone picks their argument and refuses to give.  Oh -- and before you claim that is what I am doing -- re-read what I've said.  I agree it would be ideal, but it is not NECESSARY for a recommendation to be funded.  There are still folks who can benefit.

Mike

[Since2005]

@ Bocker/Mike - First of all, I do care (in response to your comments earlier) about you, and everyone here to a point (j/k on the point). Sure, I was taken back with your abrasive comments earlier on but thanks for acknowledging it. Though, it amazes me to notice when you compare the naming/calling a third party aka govt/corp/entity’s recommendation “CRAP” with calling a forum member’s point crap/idiotic and be abrasive that way… Hope, you can also acknowledge/see the difference. Again, we may agree to disagree.

Anyways, I strongly disagree it is a GOOD recommendation (yes I am following the path of other set of docs which is to wait on the meds if its possible). Now, to get back to your point - Recommendation is not mandatory, agreed and glad we are able to enjoy that freedom as a human being. But, that’s not the point. What I don’t agree with you mainly to the fact is that you are not clearly seeing the “IMPLICATIONS” this recommendation will have. 

Let me give an example, let’s say 5 people who are HIV+ and can’t get insurance on their own. Only 3 people are allotted for benefits through govt. program (Medicare, ADAP etc.). Now, out of that 5 people, 2 of them do not need meds (good health, higher cd4 etc.), 3 of them need the meds right way (can’t wait very low cd4 etc.). Now the 2 people who could have waited starting meds per recommendation as they feel it’s a good recommendation, apply for the benefits. Remind you, funding only allows 3 people to get into programs for health benefits. Now there are 5 of them wants to get meds but 2 who could have waited (possibly due to higher cd4 count). Now, the other 2 who desperately need meds have to wait in line which in a way putting them at life-risk due to NOT HAVING ENOUGH FUNDING.

As Newt said “emperor suit” - I only can hope you could get to see now how much implications this recommendation will have. I could not agree more with Inchilgblue “ CA and NY” – doesn’t need to be a rocket scientist to figure this one out.

@Bugin – It really bugs me when I hear that you called Sean Strub “ A/Some blogger”, just to prove your point. I am not asking anyone to get medical advice from him, only doctors can provide that and if you haven’t noticed about the recommendation for the rest of the world and all parts of USA (except for two cities!! NYC and SF go figure…).  HIV is a chronic disease and you constantly have to learn about this. Look at yourself for example, how much do you know now than pre HIV. Thirty years of constant learning (pointing at Sean) on this same issue, do you have any idea how much one can learn? That’s what I meant when I said you ‘twisted’ things a bit especially when you use word like ‘untreated HIV’, ‘conspiracy’ and call a well known HIV ACTIVST a “ some blogger”, really?

@Meech – Very disappointing! With all the due respects, Meech, you have brought nothing to the table on this issue. After repeatedly been asked to show your reference(s) ( which a forum rule by the way) on the topic as you said/implied per doctors 'It is recommended to start meds as early as seroconvertion'. According to you, my references on the side effects for meds were 'half assed' researched, but, if you haven’t noticed you have done 'zero assed' research on this issue. I sure can notice your good intention but the value that you have bought to this discussion ( please go back and read your 4/5 replies) is nada.

@Eric – Interesting topic not sure I agree / understand everything on the article but thanks for sharing

@Newt – Thanks for sharing your knowledge and reference on this. I am learning about HIV and sure get to see other points of view and your comments got me exactly that. I agree as you said our body is constantly fighting due to ongoing immune activation resulting in inflammation but is it believed by most doctors that our body can handle that by itself to a certain point? As we already know about that guidelines (CD4 350 etc.). I agree inflammation can occur even people are on meds but at lower rate vs. someone who is not on meds. But, putting people on meds to control the inflammation will take me back to consider the other issues ( to avoid short or long term side effects, resources, lack of adherence issue resulting in drug resistance problems etc.).

I could definitely see how one can feel good about himself having undetective virus (as you said). You pointed out a very good point on the ‘elite controller/ long-term progressor / slow progressor' issue. If doctors take ‘ test and treat’ approach, then how one could ever find out if she/he belongs to that group?

I want to finish up by saying these –

# some people still suffer from known short-term or long-term side effects (and many unknown long-term side effects), by delaying on the meds intake, (if possible) they will be able to avoid those effects.
# waste of resources( for not being able to find out about LTP/SP or elite controller)
# Recommending this treatment approach will PUT some people ( who desperately needs meds) at health risk / life risk (by not working out a plan for allocating proper funding)
# It raises a question why SF and NYC? to reduce the HIV rate? To look out for mass?
# Majority of doctors ( counting the rest of the world) take an approach to wait and follow a standard guidelines
# Numerous researches have been done saying there are NO significant benefits to start meds early ( some of links/references were posted earlier on this thread)

Since2005 (Who would also go with majority of the doctors’ recommendation)

[bocker3]

@ Bocker/Mike - First of all, I do care (in response to your comments earlier) about you, and everyone here to a point (j/k on the point). Sure, I was taken back with your abrasive comments earlier on but thanks for acknowledging it. Though, it amazes me to notice when you compare the naming/calling a third party aka govt/corp/entity’s recommendation “CRAP” with calling a forum member’s point crap/idiotic and be abrasive that way… Hope, you can also acknowledge/see the difference. Again, we may agree to disagree.

Anyways, I strongly disagree it is a GOOD recommendation (yes I am following the path of other set of docs which is to wait on the meds if its possible). Now, to get back to your point - Recommendation is not mandatory, agreed and glad we are able to enjoy that freedom as a human being. But, that’s not the point. What I don’t agree with you mainly to the fact is that you are not clearly seeing the “IMPLICATIONS” this recommendation will have. 

Let me give an example, let’s say 5 people who are HIV+ and can’t get insurance on their own. Only 3 people are allotted for benefits through govt. program (Medicare, ADAP etc.). Now, out of that 5 people, 2 of them do not need meds (good health, higher cd4 etc.), 3 of them need the meds right way (can’t wait very low cd4 etc.). Now the 2 people who could have waited starting meds per recommendation as they feel it’s a good recommendation, apply for the benefits. Remind you, funding only allows 3 people to get into programs for health benefits. Now there are 5 of them wants to get meds but 2 who could have waited (possibly due to higher cd4 count). Now, the other 2 who desperately need meds have to wait in line which in a way putting them at life-risk due to NOT HAVING ENOUGH FUNDING.

As Newt said “emperor suit” - I only can hope you could get to see now how much implications this recommendation will have. I could not agree more with Inchilgblue “ CA and NY” – doesn’t need to be a rocket scientist to figure this one out.

Your implications have nothing to do with the science of the recommendations -- and everything to do with the funding (or lack of).  The fact that all 5 can't get it, doesn't mean that none should.  The fact that YOU think some "don't need meds yet" is irrelevant to this discussion.  The recommendation is that starting right away is good for folks health. (again -- any individual should do what is right for him/her based on discussions with their doctor).
So -- go on and disagree with the recommendations, but you can't use the "they don't need meds yet" logic to get others to join your view, because if one agrees with the recommendation (and I do), then they all need neds now.

The only problem associated with this recommendation is that not everyone CAN follow it because of funding.  Howeve, as I have stated previously, that doesn't negate the idea/facts behind it.

Mike

[wolfter]

It appears to me that even with this recommendation, a great many aren't willing to follow it.  Look how many threads contain comments regarding the fear of taking one pill a day for the rest of their lives.  And some of these people have low CD4 and high VL counts.

So, out of those 5 individuals that were just discussed, I'd guess 3 out of 5 wouldn't follow the recommendation anyways.  They don't follow their doctor's recommendation even when indicated.

There are many things the medical community recommends but that doesn't mean that everyone should automatically follow them.  Do the research and make informed personal decisions.

Wolfie 

[Assurbanipal]

Since

Your argument about early treatment potentially knocking people in greater need onto a waiting list doesn't make any sense in NYC or SF. 

They don't have waiting lists.

Since2005 (Who would also go with majority of the doctors’ recommendation)

Also, your signature says you would go with the majority of doctor opinion, which implies that you believe most doctors think one shouldn't start with your numbers.

But that would be a misstatement, at least for well-informed doctors in the US. (The ill-informed need not, I think, concern us.)

Well informed doctor opinion in the US is evenly divided -- on whether they think patients with high tcell counts should start or whether think it is merely optional to start. 

That's not a majority in favor of waiting.

 The people they agree should not start are primarily those who aren't ready to commit to treatment.




Assurbanipal

(edit.... still getting used to the new layout)

[newt]

What the US 2011 guidelines say is this:

• Antiretroviral therapy (ART) should be initiated in all patients with a history of an AIDS-defining illness or with a CD4 count <350 cells/mm3 (AI).
• ART is also recommended for patients with CD4 counts between 350 and 500 cells/mm3 (A/B*-II).

...

• For patients with CD4 counts >500 cells/mm3, Panel members are evenly divided: 50% favor starting ART at this stage of HIV disease (B); 50% view initiating therapy at this stage as optional (C) (B/C-III).

The A B C I II III of this is important. A means a strong recommendation, B means a moderate recommendation and C means an optional recommendation. Grade I evidence means randomised control trial(s) with validated clinical endpoints, II non-randomized trials or observational cohort studies with long-term clinical outcomes and III expert opinion.

Therefore on the starting at 500+ point, I disagree with concluding US doctors either think you should or have the option to start. It seems much less clear cut than the docs broadly in favour, but some being more so. They can't make up their mind at all so it's just an opinion. Some of them will recommend starting at a high CD4 count, others will go no, wait there's no data to say it's better than waiting to your CD4 count is 500 or less.

Personally, today, I would start, guidelines are not everything, but this was not what I thought when I was facing up to treatment a few years ago. Plus health policy, especially if you are looking at a public health benefit, needs to be evidence based. To get the public health benefit and economic benefit (in time) you need to have universal access  to treatment and a decent testing strategy to capture undiagnosed people, especially in the early stages of having HIV when they are most infectious. Otherwise "test and treat" don't work.

The median CD4 count at diagnosis in New York in 2008-9 was 314 (range 90–502) *, so this treating above 500 argument is perhaps moot.

- matt

* AIDS Research and Treatment Volume 2012 (2012), Article ID 869841
available at: http://www.hindawi.com/journals/art/2012/869841/

[mecch]

Since, I have nothing but friendly thoughts for you, and concern, have followed you closely since you joined our forums.
I didnt post studies because after my post Newt did give you links.
My personal take is that you are projecting your own anxiety, or fear, or ambivalence, about being HIV+ and thus the need for HAART, into an intellectual argument that you aren't arguing very well. 
You want these guidelines to be "crap" and no matter how many people explain why it isn't crap, but very serious, grown up, career, epidemiologists, research scientists, health policy experts, and doctors, coming together on a consensus about how and when to treat HIV.  As the years go by.  2000 was one story. 2005 was another. 2010 another. And now there are many cities in the world moving to this idea.  Its the same in Paris, Geneva, Berlin.  Many many doctors just think, all things considered, its advisable to offer treatment at diagnosis, even if that is early in an infection and numbers are good. Even if the nation still has more or less the American CDC recommendation.  Good for the patient.  And good for the city. Good for the community. etc etc etc.

I reported in this forum a few years ago that unofficially this was the general trend in Geneva.

You can jump through hoops over and over and over to try to avoid facing what this means to you personally, and avoid overcoming your own cognitive dissonance.  The result is arguments and taking exception to people informing you.  And your arguments are unconvincing and the name calling "crap this.. crap that" immature.

[newt]

Many many doctors just think, all things considered, its advisable to offer treatment at diagnosis, even if that is early in an infection and numbers are good.

Or not, as in UK, the USA often depending on doctor preference/whether you have public or private insurance << see the finance matters, Russia, South Africa, China, India, Brazil, nearly all of Europe << see EACS guidelines and various national guidelines, don't say start straight away, say start at 350-500 if asymptomatic, consider/recommend in some circumstances.

So people thinking the world, all those docs and patients reps working hours reviewing the evidence to draft guidelines, are moving to a consensus of immediate treatment at high CD4 counts are jumping the gun. The world is having a discussion about the merits/demerits, and individual v public benefit from ARVs.

There isn't enough data to make a consensus guideline recommendation for individual health for treatment at CD4 500+. And perhaps there is a confusion here between 1) individual benefit 2) public health benefit in this thread.

Clearly, individual doctor/patient discussions may favour early treatment. << and I am in favour, but can't justify this based on the data.

And clearly, particular docs may conclude, all things considered, early treatment is the best option at present << but can't justify this based on the data

And also clearly, as part of a package of meeting basic needs, increased testing and therefore aiming to reduce onward transmission it makes sense. << but there are only models for this not data

But the position is really not settled in terms of benefit to the individual, hence the START study comparing treatment at CD4 500+ vs 350+ or indeed how the public health benefit can be achieved without everything else aside from ARVs being in place, hence reticence in many places to go down this route.

There are no evidence-based guidelines that say treatment at diagnosis regardless of CD4 count is the best option. If I am mistaken, please post a link to the guideline here.

- matt

[Rhaegar]

Bottom line, imho, is to diligently search for a dr you trust and believe in; someone who has vast experience in treating poz patients. Someone who participates actively in research and trials and who has treated large numbers of patients. Sometimes the dr needs to rely not only on lab results but on gut feeling based on treating patiients with similar symptoms and  reactions to different meds in the past.

I cannot emphasize this enough.  My doctor chose to start me on meds the same day I received my diagnosis.  I have a K103N mutation, which I found out the following week after starting treatment, but I had already started on Truvada + Norvir/Prezista.  It could have been a lucky guess, but it was his gut feeling.  He said that starting treatment immediately would put a stop to the more damaging aspects that newt wrote about above.

Sometimes I wish there was publicly available data about a community or state's viral load in relation to each other.  Is the viral load of NYC collectively higher or lower than San Francisco?  (as an example)

[Since2005]

I cannot emphasize this enough. My doctor chose to start me on meds the same day I received my diagnosis.  I have a K103N mutation, which I found out the following week after starting treatment, but I had already started on Truvada + Norvir/Prezista.  It could have been a lucky guess, but it was his gut feeling.  He said that starting treatment immediately would put a stop to the more damaging aspects that newt wrote about above.

I believe in another thread you have mentioned that you dove right into treatment when you were diagnosed since your CD4 count was below 200 . 

I don't think your doctor was guessing!!

@assurbanipal – Please rethink about waiting list part for NYC and SF. Funds are not unlimited. I hope you did read the 5 people example. Oh yes, Majority of docs are in favor of waiting. 2 cities in the whole world!! Since when did HIV become a location specific disease? I would read Newt’s posting about the guidelines then hopefully you get to see the majority of docs opinions.

I didn’t post studies because after my post Newt did give you links.

...Many many doctors just think, all things considered, its advisable to offer treatment at diagnosis, even if that is early in an infection and numbers are good. I reported in this forum a few years ago that unofficially this was the general trend in Geneva.

YOU even went further by saying "Even sometimes within months after seroconversion.  Some even see a benefit to starting at seroconversion."
Please make your arguments based on the studies, data etc. just like Newt said. Have you even read his comments?

I will just post what Newt/Matt posted/asked for YOU to support your arguments

There are no evidence-based guidelines that say treatment at diagnosis regardless of CD4 count is the best option. If I am mistaken, please post a link to the guideline here.

Since2005 (who respects people opinions that are based on the facts even if that reflects the opposite views of his own)

***Edited to clarify...

[Rhaegar]

I believe in another thread you have mentioned that you dove right into treatment when you were diagnosed since your CD4 count was below 200 . 

I don't think your doctor was guessing. He made the right decision if I am reading your comments correctly!

Yes, I should have clarified that the guess I was referring to was about what particular treatment I should be on.  I keep forgetting that I really had no choice other to start treatment.

[spacebarsux]

Or not, as in UK, the USA often depending on doctor preference/whether you have public or private insurance << see the finance matters, Russia, South Africa, China, India, Brazil, nearly all of Europe << see EACS guidelines and various national guidelines, don't say start straight away, say start at 350-500 if asymptomatic, consider/recommend in some circumstances.

I agree completely and with the rest of your post as well.

As per my understanding, the NY recommendation was made more from a public health standpoint rather than an individual health benefit standpoint.

While it is indeed possible and may even be likely that commencing HAART upon diagnosis with CD4>500 may be beneficial in the long run, current scientific data DOES NOT conclusively prove that - and that is precisely why the START clinical trial results are so crucial.

Until and unless the START clinical trials confirm that the benefits of early treatment significantly outweigh the negatives, namely- harmful side effects, adherence and resistance issues, any assertion that early commencement of therapy is primarily for the benefit of a person’s health seems misleading at best and can also be perceived as being agenda driven.

Here in India, my doctor seemed pretty reluctant to put me on treatment until my CD4’s start hovering around the 350-400 region. When I told him about starting therapy sooner to minimize the effects of viral replication he informed me about the toxic (albeit much reduced from a decade ago) effects of the drugs on the vital organs and that in the end it is my call on when I wish to start. He’s obviously not an idiot- and what he said about toxic effects, adherence, resistance is reflected in the current WHO Guidelines, EU Guidelines, and this cannot be glossed over, at least not until we have more solid scientific evidence and data. Evidence that can honestly be described as being "Incontrovertible" or "Overwhelming". I don't think we're there today- for if we were- the WHO, EU, Africa and Asia would also be recommending a 'test and treat' approach. They are not.

 Edited to add:

The following was stated in the article linked by the OP:

“HIV experts are split about whether early therapy should be recommended or optional. Besides the high costs, the pills have side effects from nausea to liver damage. Patients unwilling to take them religiously for life could develop drug resistance. But there's growing evidence that untreated HIV can lead to cancers and heart disease. Antiretroviral drugs are safer, have fewer side effects and work better than they did in the past.”

Doctors in the US are divided on recommending early therapy or keeping it optional - which is again based on their 'expert opinions', it maybe rooted in sound medical opinion no less, but it is not yet backed by solid cohort clinical trials.

I feel until there is a clear and unambiguous consensus amongst HIV experts regarding the overall benefit of early treatment, using the word ‘recommendation’ is in itself fallacious (in so far as it pertains to the health of the individual) since such a statement rests on rather flimsy, shaky and discordant pillars. And thus, one comes to the inescapable conclusion that this so called ‘recommendation’ is more about cutting new infections than anything else- which may justify the use of the word 'recommendation' if they'd put in place a funding mechanism but since that is also lacking it’s quite nonsensical to call it a 'recommendation' in the first place.

They should label it as a "Public Health Policy Objective"

[bocker3]

Since2005 (who respects people opinions that are based on the facts even if that reflects the opposite views of his own)

OK -- time to call bull on you.....   Where are YOUR FACTS??  All you are throwing out are your thoughts.

FACT:  Some folks who are smarter than you have made a recommendation about starting treatment (repeat -- a RECOMMENDATION, not a REQUIREMENT).  You don't agree with said recommendation.  That is fine, you are entitled to your opinion.  However, you are going through all sorts of contortions, as well as, picking and choosing comments from others that seem to "support" your opinion all in an attempt to show the recommendation is "bad".  Well, you can NOT do so -- you can say all you want and it amounts to nothing more than your own opinion. 
The recommendation has been made and people will choose to follow it or not.  Honestly, I have no idea what is driving you here.  Your desire to discredit this recommendation is beyond all reason.  If you don't want to start meds -- don't start.  But please stop insulting us with all your crazy "examples" of problems that don't follow any form of logic.  Based on this recommedation, no one who starts meds would "not need them", therefore, they can't possibly be taking them from someone who does.  Why?  because they ALL need them.
This is a Public Health recommendation -- when you attain your Public Health degree, then your opinion may hold sway, for now it is simply your opinion.
Mike

[TonyDewitt]

There's so many pluses regarding the recommendation that unless you suspect a covert plan by the drug companies to make more money off of the epidemic, this is a slam dunk of sensibility. LeatherMan, I just read your well thought out analysis of how drug therapy not only saved people's lives, but also added decades of productive life (and hopefully will continue to do so). Thanks for steering us back to common sense again, along with your previous point that taking a few pills a day is a small chore for staying alive. Instead of quibbling about these things, we should be directing our concern towards the medications working indefinitely, and newer / better treatments being developed. Before there was a cure for syphilis, people would treat it by literally poisoning themselves with mercury (not sure if that would work for HIV, but would anyone want to try it?) in order to save their lives, since dying from untreated syphilis was worse than the pain, suffering, and risk of dying via mercury poisoning. Things have come a long way, and hopefully things will be going a long way too. I'd love to see LeatherMan blowing out the candles on his 90th birthday cake with the words "I told you so" written on it!

[Since2005]

OK -- time to call bull on you.....   Where are YOUR FACTS??  All you are throwing out are your thoughts.

Please re-read, FACTS are provided here -

Reply #25, Reply # 50, Reply # 55, Reply #71, Reply # 78

In addition to that, please read this below  -

http://www.medpagetoday.com/MeetingCoverage/IAC/21358
[Primary source: International AIDS Conference
Source reference:
Jonsson Funk M, et al "THLBB201: HAART initiation and clinical outcomes: insights from the CASCADE cohort of HIV-1 seroconverters on 'When to Start'" J Int AIDS Soc 2010.]

Where it talks about “Researchers suggest that using antiretroviral therapy in patients with CD4-positive cell counts of more than 500 cells/microliter has limited benefit.”
WHO, EU, ASIA, AFRICA and Majority of US (we are talking about above cd4 above 500+ etc. guidelines) who have NOT followed this recommendation -

Of course, I will raise a hell lot of questions if there are no data/guidelines supporting this recommendation. There are no evidence-based guidelines that say treatment at diagnosis with CD4 count higher than 500 is the best option. As newt suggested also, if you have ANY, please provide the guideline or links.

Since2005

[bocker3]

Since --- I'm done talking to your brick wall.  It is clear that you don't know anything about Public Health, so go on your merry way.  Maybe some day you'll get the concept of public health vs. individuals, until that time I will ignore your rants.

[Since2005]

It has already been stated NUMEROUS times in this thread about this recommendation from public health perspective.

We talked about LACK OF FUNDING
We talked about the need to put proper TESTING STRATEGIES,
We talked about convincing the general population (both US and the rest of the world) that treating people at diagnosis is actually beneficial
We talked about meeting basic needs (Housing, Universal Healthcare, etc.)

This recommendation brings no values in terms of public health (to reduce HIV rate/ stop the pandemic) unless as I agree with Inchilngblue 'put the money where the mouth is otherwise this would be pointless'.

So, either way we look at it, Individual benefits (none, due to lack of research/data etc.) vs. public health benefits (the points above) this recommendation, I would echo with others,         'It delivers nothing!'

Since2005

[leatherman]

this recommendation as I would echo with others 'it delivers nothing!'

perhaps you're just expecting too much. Do "recommendations" ever deliver anything? Aren't recommendations like "suggestions" and not definitive "policy"? Won't a recommendation actually slowly be putting into place the necessary underpinning for the possible future policy? That is, won't this recommendation make doctors begin to consider treating patients earlier? won't it make policy-makers begin to consider more funding sources and pricing schemes? Won't it make health departments and clinics being to plan about the amount of patients that will need to be seen and begin to set up resources to treat those new clients?

Thank goodness a recommendation isn't expected to immediately go into effect because without the right about of doctors, funding, clinic space, etc there would be no way to accomplish this kind of recommendation.  However, by putting out a recommendation like this the healthcare system is able to "gear up" and get resources lined up (and that includes funding) so that the recommendation can be fully implemented and actually then become public policy.

[Since2005]

perhaps you're just expecting too much. Do "recommendations" ever deliver anything?

This one does. I should not have said nothing rather should have said it does deliver lots of wastes. Here it is -

The IMPLICATIONS of this recommendation will have some IMMEDIATE EFFECTS as I stated earlier -

1.   Some people are going to suffer from side effects that they could possibly avoid
2.   Some people would still suffer from drug resistance problems due to lack of adherence issues
3.   Waste of resources( for not being able to find out about LTP/SP or elite controller)
4.   Recommending this treatment approach will PUT some people ( who desperately needs meds) at health risk / life risk  due to sudden increased competition and lack of proper funding)
5.   Numerous researches have been done saying there are NO significant benefits to start meds early ( some of links/references were posted earlier on this thread)  and therefore, people are going to be put on meds Unnecessarily.

These are the RISKS will be immediately effective unless some of these below gets taken care of by the providers. Can policymakers implement any of these?

1.   Universal Healthcare
2.   Other basic needs ( housing, foods, other social benefits etc.)
3.   Near 100% perfect TESTING STRATEGIES ( have to catch everyone!)
4.   PROVE that starting meds at 500+ is beneficial ( NO DATA proves that)
5.   The whole world has to be in it ( not just parts of USA) to stop the pandemic

Is it doable? achievable? The REST OF THE WORLD follows a guidelines for starting meds at cd4 350+ etc. By recommending this in TWO cities in USA will have almost none/zero impact unless all five things gets implemented to say the least.

Public health officials have to achieve all 5 of them. Unfortunately, NONE EXISTING at the moment and the given reality that we are in, none will be available in any near future ( e.g. # 1 universal healthcare).

Then, why waste resources? put people at risks or let them suffer? Avoid people who could have been a LTP or elite controller? These are people we may need to lead to a possible cure ( hopefully). But, that's not the end of it, After all these damages, the goal aka Public health issue STILL WILL NOT BE SOLVED.

This  recommendation brings nothing but sufferings (side effects, waste of resources, drug resistance problems, putting people at risks due to lack of funding etc.) because of the IMMEDIATE IMPLICATIONS that it will have. So, what else should we call it? BIG BULL CRAP. Sure go ahead...

[mecch]

The IMPLICATIONS of this recommendation will have some IMMEDIATE EFFECTS as I stated earlier -

1.   Some people are going to suffer from side effects that they could possibly avoid

Maybe a few, out of thousands who benefit, and those few would suffer just on or two years more than otherwise.  This is a weird fear. For example, what is difference nowadays if someone seroconverts and then starts HAART after 6 months or a year, rather than 2 or 4 or 6 years or later? Say the hypothetical sufferers you mention are 30ish. They will be living a normal lifespan.  I think the hypothesis nowadays is minimal side effects, generally, mostly, for newish infections going on current HAART and looking toward the future.

2.   Some people would still suffer from drug resistance problems due to lack of adherence issues

That happens but has no relation to the time after sero-conversion one is put on HAART.  You seem to be always assuming a recommendation for early treatment will be mandatory and push people onto something they are not ready for? Or can’t afford? Or what?  Any doctor with a patient observed to be a potential risk for adherence is going to treat that person accordingly.  With or without the changed CD4 recommendations.

3.   Waste of resources( for not being able to find out about LTP/SP or elite controller)
This elite controller fear seems to be pure projection of a personal wish or regret.

Science has identified enough elite controllers for their research needs. This fear of yours is of no concern to the entire HIV+ population.   If some individual HIV+ person has a zero viral load or very low viral load, every doctor is going to use a “special case” protocol when advising this person when and why to start HAART.  It is an exceptional situation.   Also you have mistakenly assumed that early treatment recommendations means before set points are observed and the recommendation doesn't say that specifically, at all. 


4.   Recommending this treatment approach will PUT some people ( who desperately needs meds) at health risk / life risk  due to sudden increased competition and lack of proper funding)

If tomorrow a city decides among its population of known HIV+ people, a lot more should be offered treatment, following a recommendation, it does NOT mean people already on treatment are going to lose their access.   If a city, state, nation knows “100” people could benefit from treatment, but can pay for only 50, nothing changes from the current situation that says only 60 of 100 of those people need treatment, and they can only pay for 50. Its still just 50 treatments. Its a funding issue.

5.   Numerous researches have been done saying there are NO significant benefits to start meds early ( some of links/references were posted earlier on this thread)  and therefore, people are going to be put on meds Unnecessarily.

I agree about your presentation of the science. But the “unnecessarily” is only based on your arguments 1-4, which are not very good.