50% of Specialist Panel says Treatment at Diagnosis

[mecch]

Suppose many of you have read this news post:

http://aidsmeds.com/articles/hiv_treatment_guidelines_2042_17726.shtml

The panel now recommends people with CD4 cell counts of 500 or below start HIV treatment right away. Previously, the guidelines recommended waiting until CD4s fell to below 350. The panel was split 50/50 about whether people with over 500 CD4s should start; half of the panelists essentially recommended treatment for everyone with HIV.

I'm not really up on the situation in the USA but can tell you in Switzerland, where we have universal health coverage, not coincidentally, more and more doctors are prescribing HAART as soon as the Pozzie is willing to commit.

So what do you all think about this development? 

I'm kind of a special case cause I never had the choice to refuse HAART.

I wonder who's gonna pay for all this, by the way.

[tommy246]

I think this says two things mainly the first is that there is a growing amount of evidence of what long term damage untreated hiv causes even with decent cd4 counts immflammation etc and secondly a major pat on the back for modern meds which most people starting for the first time tolerate very well with few if any side effects that will keep you non detectable for years if you adhere not allowing mutations so not running out of med options.
Early meds couldnt completely supress the virus allowing it to mutate making the meds useless and were extremely toxic causing major health problems so it was logical to let people wait as long as possible before starting  at 200 cd4 as the meds did more damage than the hiv. That has all changed thats why for people just starting  first time on modern meds its now considered  a chronic illness.

[Miss Philicia]

My only reservation is that we've been down this road before with "Hit Hard, Hit Early" which I think became the standard once HAART was introduced.  Then they started seeing too much lipo issues and reversed course.  Now, I'm also fairly firmly of the mind that the newer generation of meds does not do such things, but then the conservative side of me says that if you're above 500 then why risk it.  I've long thought that it was better to go on meds before going down to 350 though.

I'd assume that my reservations are similar to the 50% that aren't advocating this new line of thinking.  And when something is split like that I'd err on the side that I'm more familiar with.  Of course, I may change my mind as time goes on.

[newt]

What Miss P said....

The research suggest above 350.

Below 500 is a conceptually different matter.

If I started today, it would be at 300+ but under 500? That could be a looooooong time extra on drugs. Clearly, different people will make different choices, but what if, say, your CD4 stayed around 400 for ages? This does happen.

- matt

[Miss Philicia]

And also to consider, if the patient has been regularly testing for HIV every six months or so for eons and can then somewhat pinpoint their infection date, it's so very feasible to take a wait and see attitude post-infection with lab numbers.  Of course, while I have no firm stats, we all know that a sizable amount of people were not testing that regularly pre-diagnosis.  But it is another consideration in the equation I would think.

[madbrain]

Hi,

Suppose many of you have read this news post:

http://aidsmeds.com/articles/hiv_treatment_guidelines_2042_17726.shtml

The panel now recommends people with CD4 cell counts of 500 or below start HIV treatment right away. Previously, the guidelines recommended waiting until CD4s fell to below 350. The panel was split 50/50 about whether people with over 500 CD4s should start; half of the panelists essentially recommended treatment for everyone with HIV.

I'm somewhat surprised about the recommendation to start above 500 CD4, given the lack of research in such patients. I think there are a lot of factors that can affect the choice to go on therapy immediately or not.

For example, the rate of CD4 decline in the patient over time, the age of the patient and how long he would be expected to be on HIV therapy and suffer potential side effects, and how easily the person has access to meds so that he would be guaranteed uninterrupted access to them after starting.

In countries without universal health care, especially the USA, it is all too easy for someone to lose their insurance or other access to meds, even though past studies have shown that most people cannot safely interrupt their HIV treatment once started due to resistance.

Much research also remains to be done in the area of inflammation. Just how bad is it to have long-term low-level HIV viremia, vs the known side effects of taking the meds long-term ?

Personally, with no CD4 decline (even a slight increase) at 3 years into HIV, and very low HIV VL, it is difficult for me to make the case that I should have gone on meds at diagnosis. I would very much like to see data in other people that have chosen to go through treatment with numbers like mine, and see how they fared. I haven't been able to find any so far.

I'm kind of a special case cause I never had the choice to refuse HAART.

What do you mean, are they force-feeding you the pills over there ?

[Inchlingblue]

It's been shown that those who start within the first year have smaller reservoirs and they are made up of one type of Tcell. As things progress, reservoirs get larger and another type of Tcell is affected. This could have implications when progress is made in efforts to eradicate virus from reservoirs. I'm not saying it's a deciding factor in starting early but it's one more thing to consider.

Also, the longer one waits, the more chances of developing dual-tropic virus (CXCR4 and CCR5). If one's virus is made up of CCR5 only, there are much more promising therapies being developed for eliminating it.

LINK:

http://www.natap.org/2009/HIV/062609_01.htm

[madbrain]

Thanks for this reference, Inchingblue.

It's an interesting article. But all the patients in the study had CD4 depletion prior to initiating HAART, whether they started HAART early or late. The researchers didn't study anyone with stable CD4 counts that didn't go on HAART, with low-level viremia. My take from the article is that the size of the HIV reservoir grows as CD4 cells are depleted, and initiating HAART early halts CD4 cell depletion and thereby reduces the size of the HIV reservoirs.

Since I have experienced no statistically significant CD4 cell depletion over time - my most recent lab result was my highest CD4 count to date -, I can't really say that this does much to convince me that I should have started HAART 3 years ago at diagnosis instead of still not being on it today. I suppose I'm an unusual case as an HIV controller, but I think the subject merits further study.

It's been shown that those who start within the first year have smaller reservoirs and they are made up of one type of Tcell. As things progress, reservoirs get larger and another type of Tcell is affected. This could have implications when progress is made in efforts to eradicate virus from reservoirs. I'm not saying it's a deciding factor in starting early but it's one more thing to consider.

Also, the longer one waits, the more chances of developing dual-tropic virus (CXCR4 and CCR5). If one's virus is made up of CCR5 only, there are much more promising therapies being developed for eliminating it.

LINK:

http://www.natap.org/2009/HIV/062609_01.htm

[Inchlingblue]

Yes, high nadir CD4 is important but they clearly state three variables that affected reservoir size, high nadir CD4 being one:

We observed that CD4/CD8 ratios >1, high nadir CD4+ count and initiation of HAART within the first year of HIV infection are strongly associated with an HIV reservoir of limited size (P < 0.0001, P = 0.0005 and P < 0.0001, respectively; Fig. 2a-c).

They also say:

Our results indicate that HIV persists in two reservoirs that are maintained by distinct mechanisms. Individuals who have started treatment early in infection carry a viral reservoir of limited size that is harbored mainly by TCM cells, which have the capacity to survive for long periods of time

Do you know what your CD4 nadir is so far? Based on your sig. line it was 553, which is pretty high for a nadir, LOL.  Has your CD4/CD8 ratio always been >1?


I can't find where it says that all the participants had CD4 depletion before the study. I'm not implying it's not there, but can't find it. Can you point it out? Thanks.
 

[madbrain]

Hi,

Do you know what your CD4 nadir is so far? Based on your sig. line it was 553, which is pretty high for a nadir, LOL.  

Yes, 553 was my lowest CD4 count.

Has your CD4/CD8 ratio always been >1?

No, actually it's never been. I don't put these in my sig, but I just looked at a few labs. Kaiser used to have a separate line for CD4/CD8 and showed a normal range of 0.74 to 5.30 for this ratio. My first result at diagnosis was 0.77 . They no longer list the ratio in more recent labs. But I calculated it and it is 0.756 in my last labs, basically unchanged.

I can't find where it says that all the participants had CD4 depletion before the study. I'm not implying it's not there, but can't find it. Can you point it out? Thanks.

Maybe I misinterpreted it, I glanced over it quickly. The PDF contains 11 references to CD4 t-cell depletion.  Some of these references are used when discussing the results of the study, for example in the first line of the description of Figure 2.
Also on page 7, "We found that CD4+ T cell depletion is accompanied by increased amounts of IL-7 ..." . Even if it's not very clear, the way I read it is that there was t-cell depletion in the subjects of this study. I didn't mean to imply that the CD4 depletion happened prior to the study, only that such depletion was experienced in the subjects, as with most HIV-infected patients.

Until one studies the effects of HAART in people with little or no long-term CD4 depletion, ie. HIV controllers, I am slightly skeptical of the benefit of recommendations that everyone with HIV gets on HAART. It would help a lot if I had any idea what my pre-HIV CD4 count was. Perhaps it was higher than it is now. I don't know. And if it was higher, given a non-declining CD4 count, I also don't know if going on HAART would help me return to that hypothetically higher count. The benefit of going on HAART for me at this point in time is not clear.

[mecch]

What do you mean, are they force-feeding you the pills over there ?

Genetically I cannot control the virus on my own. Xpress progressor.

[Ann]

Genetically I cannot control the virus on my own. Xpress progressor.

How do you work that out? You are basing this assumption on labs from the first three months of your infection. You never gave your body a chance to sort hiv out on its own. For all you know, by the time you reached the six or nine month mark, your numbers could have been fantastic without the meds. You cannot realistically state that you are an "xpress progressor" based on the first three months of infection, any more than a person could declare themselves to be a long-term non-progressor based on the first three years of infection. Get real.  Sheesh.

Ann

[mecch]

Ann, you are going off topic perhaps. But to set the record straight, that is not my opinion, that is the opinion of two principal HIV specialists in Switzerland, based on my numbers.  They have combined seen many thousands of HIV patients, for decades. They are doctors, chiefs in important Swiss hospitals. I think their statement on my experience is more valid than anything I can say or you can give attitude about, since neither of us are doctors.  Voila. ("SHEESH!" really?)

[minismom]

When Mim tested poz in 2000 (reminder - she was tested at 6wks old and diagnosed at 8wks old), her ex-PID told us that most doctors wouldn't start an infant on meds until they were a year old.  However, she wanted to start Mim on meds right away based on her numbers.  At that point, it sounded like an excellent idea - she's sick = put her on meds.  Looking back, taking into account of what I know now, and seeing what being on meds has done (although I'll admit that no one knows for sure how many of her issues are med-based and how many are virus-based), I wish we would've waited for a few more tests to determine her trend.

 Then again, I'm not sure if an infant's immune system has the ability to sort this kind of thing out on its own or not.  Would love your take on this, Newt.  Not sure if waiting would've really made that much of a difference in the side-effects or just made her over-all health that much worse.  Unfortunately, we'll never know.  I'd like to think that waiting until necessary is the best option.  But, then "necessary" means different things to different people.  Certainly a good discussion topic.

BTW, what is an "xpress progressor"?