Experiences from Daily Practice

Even if the indication for HAART seems obvious, a conversation with the patient should clarify whether he or she is indeed prepared to start treatment. The problem is not the initiation of HAART, but its continuity, day after day, month after month. The decision to initiate treatment is often made prematurely. In some cases, patients put themselves under pressure unnecessarily, or let others do so. A single lower CD4 count value, a prolonged case of flu seeming to indicate a weakened immune system ("I never had anything like that before"), springtime lethargy, new study results, a promising new drug in the newspaper ("I've heard so much about X"), a partner who has started therapy - none of these are indications for initiation of treatment.

As a rule, as much time as is needed should be taken for the decision to start therapy. This is usually possible. A well-informed patient complies better with treatment and adherence! We recommend that patients come for several consultations to prepare for treatment. There are two exceptions: patients with an acute HIV infection, and those with severe immunodeficiency or AIDS. However, even in the presence of most AIDS-defining conditions, the acute disease should often be treated first before initiating antiretroviral therapy, as the potential for complications with PCP, toxoplasmosis or CMV therapies unnecessarily jeopardize treatment options. Not a single study to date has shown a benefit of commencing HAART simultaneously with OI therapy.

If a long vacation is planned, it is better to delay therapy so that treatment response and side effects can be adequately monitored. On the other hand, patients may sometimes find one reason after another (stress at work, exams, change of job, etc.) to delay initiation of treatment. Many patients are afraid of AIDS, but often just as afraid of HAART ("the pills are the beginning of the end!"). They may have irrational or simply false expectations of HAART and its consequences - starting therapy does not mean that one will be subjected to daily infusions and no longer able to work!

Therapy should be explained to every patient from the outset. It is also useful to define individual threshold values for the commencement of therapy with patients early on, so that therapy is started only when these levels are reached. In our experience, patients are more motivated by this approach.

We also tend to start HAART earlier in older patients (above 50 years). The regenerative capacity of the immune system in older patients is significantly reduced (Ledermann 2002, Grabar 2004). More importantly, the risk of developing opportunistic infections not only depends on viral load and CD4 count, but also on age (Phillips 2004). Another example from the CASCADE Study cited above (Table 5.1) exemplifies this: a 25 year-old with 100 CD4 cells/^l and a viral load of 100,000 copies/ml has a risk of approximately 10 % for developing AIDS within six months - for a 55 year-old, this level of risk is reached at 150 CD4 cells/^l and a viral load of 30,000 copies/ml!

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