Monday, 28 September 2009

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CD4 and starting ART: time to revise the guidelines?

When should anti-retroviral treatment (ART) start? According to World Health Organisation guidelines for ‘resource-limited settings’, treatment should start before the CD4 count falls below 200 cells/mm3. ‘Consideration’ should be given to treating patients with a CD4 count below 350.  

Based on the WHO guidelines, NACO’s guidelines on ART recommends waiting to treat those with mild or no symptoms until their CD4 count falls below 200. The threshold for treatment has been much higher in the West (350 in the US) and Indian groups have protested this double standard. The latest studies suggest that that a higher threshold means more lives are saved.  

The When to Start Consortium analysed 18 studies covering 45,000 patients in Europe and North America and found that the minimum CD4 count should be 350. People starting at lower counts were at higher risk of death. 

However, Robin Wood and Stephen Lawn of the Desmond Tutu HIV Centre at the University of Cape Town in South Africa warn that these findings may not apply in developing countries. Commenting in the Lancet on the Consortium’s paper, they state that the drugs used in such countries are more toxic and their side effects will have to be balanced against the risk of later treatment. To change international guidelines we need research in developing countries, they write.  

Doctors do your duty… 

The healthcare profession needs to pull its socks up. Here are some complaints reported in the AIDS-INDIA egroup: 

People using the ART Centre at the Coimbatore Medical College and Hospital have complained about the substandard treatment they have received here. The Covai district HIV Ullor Nala Sangam writes that doctors here avoid conducting surgery on positive people. The ART ward nurse doubles up as the pharmacist so she can’t visit wards. Though the blood bank is run by the Tamil Nadu State AIDS Control Society, blood is not available to positive people when they need it.  Also in Tamil Nadu, G Karunanithi, vice president of the Tamil Nadu Network of Positive People, writes that an eight-year-old girl died on April 17, apparently because she did not get appropriate medical treatment. For the last year the child was shuttled between the Community Care Centre at Krishnagiri and the Children’s Hospital at Egmore, seeking treatment for various opportunistic infections.  

In Delhi, Hari Singh, counsellor at a drop-in centre run by the Delhi State AIDS Control Society narrated the story of a couple who had worked in a hospital for 12 years before they tested positive. The man had been admitted for treatment of an opportunistic infection at the same hospital and was tested for HIV without counselling. When he tested positive, he was referred elsewhere. The health of the couple improved after they started ART, but when they tried to return to their jobs, they were told they had been dismissed. 

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