When to start HAART

[tripwm]

So I've seen a lot of recommendations on HAART therapy, but when is the general consensus to start HAART in an otherwise asymptomatic patient (or at least what the USMLE likes to say)?

CD4<500- I've seen this recommendation before.

CD4<350- I've seen this one as well.

CD4 w/e with an HIV dx?- Heard some discussion on this.

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[res1cue]

My understanding is general consensus is cd4 of 350, as it has proven benefit

Between 350-500 possible benefit

For testing, i would go with 350

 

[igcgnerd]

Current recommendation I see the NBME going of of:
Cd4<400 or an AIDS defining infection regardless of CD4

 

[alpinism]

Just to be clear, Regardless of what the NBME says, if you're dealing with real patients in the real world everyone HIV+ should be started on ART.

From the current practice guidelines:

The recommendation to initiate ART in individuals with high CD4 cell counts—whose short-term risk for death and development of AIDS-defining illness is low6,7—is based on growing evidence that untreated HIV infection or uncontrolled viremia is associated with development of non-AIDS-defining diseases, including cardiovascular disease (CVD), kidney disease, liver disease, neurologic complications, and malignancies. Furthermore, newer ART regimens are more effective, more convenient, and better tolerated than regimens used in the past.

http://aidsinfo.nih.gov/guidelines/...10/initiating-art-in-treatment-naïve-patients

 

[tripwm]

Just to be clear, Regardless of what the NBME says, if you're dealing with real patients in the real world everyone HIV+ should be started on ART.

From the current practice guidelines:

The recommendation to initiate ART in individuals with high CD4 cell counts—whose short-term risk for death and development of AIDS-defining illness is low6,7—is based on growing evidence that untreated HIV infection or uncontrolled viremia is associated with development of non-AIDS-defining diseases, including cardiovascular disease (CVD), kidney disease, liver disease, neurologic complications, and malignancies. Furthermore, newer ART regimens are more effective, more convenient, and better tolerated than regimens used in the past.

http://aidsinfo.nih.gov/guidelines/...10/initiating-art-in-treatment-naïve-patients

Roger on that. Gotta get to the point where I will be the one calling those shots first .

 

[Lokhtar]

So I've gotten this question wrong on question banks because on my IM rotation we had a lecture from a HIV-specialist who says that everyone should be treated as alpinism mentioned above. The question banks disagreed.

Those are indeed the new guidelines. I am not sure if the STEPs have caught up yet - for me, if those are the guidelines, that's what you should answer. Just because the qbanks haven't caught up, doesn't mean you'll be marked wrong on the actual NBME exams for that answer. Those guidelines are now more than a year old and are from the NIH, CDC and the Infectious Disease Society of America. You can't get any more 'standard of care' than having all of those organizations release an official set of evidence based guidelines .

Just my 2 cents.

ON a random note, reading through those guidelines, zidovudine is no longer recommended as part of initial therapy for new patients either. Interesting.