To treat or not to treat HIV

[match2011]

HIV
CD4 450
HIV RNA 40,000

To treat or not?

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[OveractiveBrain]

HIV
CD4 450
HIV RNA 40,000

To treat or not?

CD4 <200 or AIDS defining illness. Treat. Duh.
CD4 <350. Treat (newly decided)
CD4 <500. Meh urh uh. Maybe?

If resources and patient compliance aren;t an issue, then you can. But most HIV patients are poor and ignorant. NA-ACCORD study showed a mortality benefit by starting at a CD4 less than 500 and totally asymptomatic, but they excluded the typical HIV patient.​

CD4 >500. Definitely not. Watch and monitor.

You shouldn't be making these decisions on step 2. I guess, if you are staying current, the answer is yes, since compliance and resources aren't an issue on Step 2. I can't imagine that's the question they'd ask you though...

 

[match2011]

CD4 <200 or AIDS defining illness. Treat. Duh.
CD4 <350. Treat (newly decided)
CD4 <500. Meh urh uh. Maybe?

If resources and patient compliance aren;t an issue, then you can. But most HIV patients are poor and ignorant. NA-ACCORD study showed a mortality benefit by starting at a CD4 less than 500 and totally asymptomatic, but they excluded the typical HIV patient.​

CD4 >500. Definitely not. Watch and monitor.

You shouldn't be making these decisions on step 2. I guess, if you are staying current, the answer is yes, since compliance and resources aren't an issue on Step 2. I can't imagine that's the question they'd ask you though...

How about the HIV RNA level? Do we need treat it when the HIV RNA level is more than 10,000?

 

[Slevin]

If I remember correctly you don't treat the viral load but you treat based of of SSx and CD4 count

 

[OveractiveBrain]

How about the HIV RNA level? Do we need treat it when the HIV RNA level is more than 10,000?

NA_ACCORD just released recommendations. Viral Load is not considered. Only CD4 count and the presence of opportunistic infections.

I learned on my medicine rotation in medical school that it was CD4 of 200 or opportunistic infections, start, otherwise don't bother. That always bothered me. Why not start earlier? Well, I;ve been answered. There just wasn't enough data yet to say so.

If you are worried about being too current for your test. CD4 200 or Opportunistic infections, start. If not, don't start.

 

[match2011]

NA_ACCORD just released recommendations. Viral Load is not considered. Only CD4 count and the presence of opportunistic infections.

I learned on my medicine rotation in medical school that it was CD4 of 200 or opportunistic infections, start, otherwise don't bother. That always bothered me. Why not start earlier? Well, I;ve been answered. There just wasn't enough data yet to say so.

If you are worried about being too current for your test. CD4 200 or Opportunistic infections, start. If not, don't start.

From MTB2:

1. CD4 < 350
or
2. RNA > 100,000
or
3. opportunistic infection occurs

 

[OveractiveBrain]

From MTB2:

1. CD4 < 350
or
2. RNA > 100,000
or
3. opportunistic infection occurs

New England Journal of Medicine
http://www.nejm.org/doi/full/10.1056/NEJMe0902713 (editorial)
http://www.nejm.org/doi/full/10.1056/NEJMoa0807252(original article)

Confirmed in Mandell, Infectious Diseases (even before the NEJM articles). Viral Load is only used to monitor efficacy of treatment, not to give you a start point. I can't imagine that the Step would not be aware of this if its already in a textbook. I would say MTB is actually WRONG by saying to start at a Viral load > 100,000

But like I said, the Boards may not be up to date yet with a newlyish published article. MTB is a review book, and can be riddled with errors. Although... 100,000 sounds like an awful lot, like their CD4 would plumit lickity-schplit quit, so maybe...

MTB is the only Kaplan product I don't like.

 

[OveractiveBrain]

From MTB2:

1. CD4 < 350
or
2. RNA > 100,000
or
3. opportunistic infection occurs

So I know where the 100,000 thing came from. There is a recommendation that you COULD treat (not SHOULD) if the viral load is > 100,000. This is a current recommendation since initiation of HIV treatment is based on the CD4 count, pregnancy, and AIDS infection.

In 2003 there was a suggestion that treatment goes like this:
History of AIDS-defining illness - treat
CD4 <200, even if asymptomatic &#8211; treat
CD4 201-350 treatment recommended
CD4>350 with VL >100,000- treatment recommended
CD4 >350 and VL <100,000 &#8211; treatment discussed but not generally recommended

This is old and does not reflect the current evidence but does go along with some ID website's guidelines.

Now, it goes like this
History of AIDS-defining illness - treat
CD4 <200, even if asymptomatic - treat
CD4 <350, even if asymptomatic - treat
CD4 >350 - treatment recommended
CD4 >500 - discussed, but generally not recommended

 

[match2011]

So I know where the 100,000 thing came from. There is a recommendation that you COULD treat (not SHOULD) if the viral load is > 100,000. This is a current recommendation since initiation of HIV treatment is based on the CD4 count, pregnancy, and AIDS infection.

In 2003 there was a suggestion that treatment goes like this:
History of AIDS-defining illness - treat
CD4 <200, even if asymptomatic – treat
CD4 201-350 treatment recommended
CD4>350 with VL >100,000- treatment recommended
CD4 >350 and VL <100,000 – treatment discussed but not generally recommended

This is old and does not reflect the current evidence but does go along with some ID website's guidelines.

Now, it goes like this
History of AIDS-defining illness - treat
CD4 <200, even if asymptomatic - treat
CD4 <350, even if asymptomatic - treat
CD4 >350 - treatment recommended
CD4 >500 - discussed, but generally not recommended

Thanks
Got it