Initiating HIV/AIDS Therapy in Treatment-Naïve Patients At what CD4+ cell count should you start HAART?
	Enlarged Version of Graphics Below	Announcer (VO): The DHHS guidelines recommend treatment for symptomatic patients and asymptomatic patients with CD4 cell counts below 200. Treatment can also be offered to asymptomatic patients with CD4 cell counts above 200 and below 350.   See Slide Announcer (VO): Most clinicians defer therapy in asymptomatic patients with CD4 cell counts above 350 and viral loads above 100,000. In such patients where the viral load is under 100,000, the guidelines recommend deferring therapy.   See Slide Dr. Kwakwa (OC): Well, I will speak for myself, and start out by saying that I tend, for example, to initiate therapy perhaps at higher CD4 counts than many people would interpret the guidelines as suggesting, particularly in women.... Dr. Kwakwa (VO): ....but in those patients who come in to see me with higher CD4 counts, and in those patients with whom I have an opportunity to initiate therapy sooner rather than later, I tend to do that. In women, I have initiated as high as 400. In men, I do tend to initiate within the 200 to 350 CD4 guideline, but I tend to initiate closer to the 350 than to the 200 whenever I have an opportunity, of course if the patient is ready. In patients with hepatitis C coinfection as well, in an effort to preserve the immune competence, I tend to start sooner rather than later in those patients also.   See Slide Dr. Wohlfeiler (OC): The CD4 criteria that are in the guidelines are great. They're very helpful. But there's nothing magic that if a patient's got a CD4 count of 351, that they're that much different than someone who's got a CD4 count of 349. I think that part of what you have to look at is you have to look at trends. If I've got a patient who's in say, the mid 200s, but they've been there for a while. They're stable. Even though they fall into the area where it would certainly be appropriate to start them on antiretroviral therapy, if that patient is not ready to start therapy, and if they're stable, I often will do nothing more than monitor them. And I've seen patients remain stable in that range for years before needing to start antiretrovirals.
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