Re: Re: Re: Re: Some Random Comments 4 November 2004
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Peter J Flegg,
Physician
Blackpool, UK

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Re: Re: Re: Re: Re: Some Random Comments

Further to Mark Bartlettís questions concerning immunological changes in successful long term HIV, there are other recent studies indicating the beneficial effects of this treatment strategy on lymphocyte subsets. ACTG 315 (1) reported on 20 HIV patients with moderate immunodeficiency who had HIV-RNA levels persistently below 1000/ml through years 3-6 of HIV treatment. This study showed similar CD4 changes over time as we have discussed in other studies, with a median rise within year one of 159 cells/mm3, but a levelling off after 3 years (median rise 42/mm3 between years 3 and 6).

Despite these improvements, CD4 counts (absolute, naÔve and memory) still remained at a level below those of HIV-uninfected subjects. Persistent immune activation appears to still be occurring, for reasons that are unclear, although continued low level viral replication could not be ruled out. Thymus size also increased during the study as assessed by CT scan.

In the interests of complete objectivity, I must reveal that in year 6, eleven of the patients had a drop in their CD4 count. (I mention this with some trepidation, as it may be seized upon by watching HIV-dissidents and quoted out of context as clear proof that HIV therapy is useless).

It seems that the earlier one treats HIV with HAART, the more complete will be the immune reconstitution. If HIV drugs were cheap and harmless, there would be no doubt that the therapeutic strategy would be to start treatment as soon as possible. However, until the risk-benefit equation shifts in this direction, it seems more appropriate to wait until treatment is clearly indicated, even if this is at the expense of having suboptimal immune recovery.

(1) Smith K et al. Long term changes in circulating CD4 T lymphocytes in virologically suppressed patients after 6 years of highly active antiretroviral therapy. AIDS 2004 (18)14;1953-1956.

Competing interests: None declared