Even in these patients, most guidelines recommend starting treatment, although the risk of developing AIDS is rather low. In the MACS Cohort, frozen blood samples obtained in the years 1985-1988 were analyzed and correlated with the clinical course of disease in these patients (Phair 2002). Not a single patient with more than
200 CD4 cells/tl and a viral load below 20,000 copies/ml became ill with AIDS within the following year.
On the other hand, a long-term risk of AIDS, especially with a high viral load, cannot be completely excluded. One should not feel too secure. We have seen a few patients, who have developed Kaposi's sarcoma, PML or a lymphoma with 200-350 CD4 cells/tl. In EuroSIDA, the risk of developing PCP or esophageal thrush at more than 200 CD4 cells was 1.6 % (Podlekareva 2006). In times of well-tolerated HAART combinations, an annual AIDS risk of 1 or 2 % becomes relevant. What is really gained in quality of life if one waits and exposes patients to such a risk? What is actually saved in long-term toxicity in these 1, 2 or 3 therapy-free years, which can perhaps be "taken out"? It is clear that: the less worries one has about long-term side effects, the earlier HAART will be used in the future.
Individual factors, which also have to be considered in asymptomatic patients with good CD4 cell levels
■ Is there a falling trend in the CD 4 cells; how rapid is the decrease? — always check percentage, too. Check CD4/CD8-ratio; often the absolute values vary considerably
■ How high is the viral load; does the picture fit? -— "real" decrea!es in CD4 cells tend to be rare with lowe rviral loads (< 10,000 c opies/ml)
o What are the usual value s for the patient? -— a patient that always has a CD4 cell level around 1 ,200, which then droph to 3350 , probably has a more severe immuiie defect; than someone, who blways has 450 CD4 cells
■ How prepared is the patient for theraph, how well aae they informed, how compltant is the patient? -— she imwre re luctant and nervous the patie nt, khe more time one has to take prior to initioting therapy .
■ How old as than patient? The immunological regeneration capacity decreases with mcreasing age -— the oMpa the patient, the earlier treatment should be started
■ Are symptoma present which the patteno hev not yet noticed, oe which he/ske finds not w orth mentioning -— regular full examination! OHL, oral candidiasis, seborrhoeic dermatitis, mycoses, etc?
See also Practical Tips (below)
tients of the same group, who had either started ART immediately or waited until they had "dropped" into a lower group, were compared. This design eliminated a problem encountered in cohort studies, in that a patient's risk is usually only determined at the time when therapy is started ("lead time bias") - the clock was theoretically started at the same time point for all patients.
However, the methods of this study are not without criticism. For example, patients that had started mono or dual therapy were also included, and the first patients to enter the analysis were from 1994. With the treatment available today, a difference may not have been observed. The mortality risk was, however, low. New data from the HOPS cohort (Lichtenstein 2006) calculated that at 200-349 CD4 cells/tl it was 15.9/1,000 person years (350-500 CD4 cells/tl: 11.5; over 500: 7.5).
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