WHEN TO START HIV TREATMENT SOON VIRUS DETECTED OR PER CD4 COUNT-350 THEN 500 CONTROVERSARY BUT CDC FOR EARLY

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A debate is raging between activists over whether treating HIV when CD4 cells are high is scientifically sound as “Hit early and hit hard.” That was the HIV treatment philosophy at the dawning of the antiretroviral (ARV) era in the latter part of the 1990s too as emerging today but then Such boldness eventually shrank due to high drug toxicites resulting in drug non complaince resistance and more death and complications as few drugs with more toxicity were aavialable.So in 1998, U.S. Department of Health and Human Services (HHS) treatment guidelines stated that anyone with a CD4 count below 500 should be offered treatment. But by 2001 the agency’s treatment panel did an about-face, recommending ARVs only to those with fewer than 200 CD4 cells. 
In the years since, treatments have become progressively simpler and less toxic as research has increasingly supported the benefits of earlier treatment. Study after study has found numerous harms associated with allowing the CD4 cells to drop lower than 350. Research suggests that people with HIV are “haunted” by their lowest-ever CD4 count: A lower number can set them on a course for greater health problems over time. Furthermore, a freely replicating virus appears to raise the risk of a host of diseases not directly associated with AIDS, including cardiovascular, kidney and liver diseases, and non-AIDS defining cancers. 
Given such findings and the vastly improved crop of ARVs, federal guidelines on when to start treatment have steadily marched back toward those of 1998—but not entirely. Because when it comes to answering the question of starting treatment when CD4s are above 350, the available scientific data on the matter is not conclusive. This is because the evidence comes from observational trials instead of from the gold standard of scientific research, a randomized controlled trial (RCT).

This uncertainty didn’t stop the Centers for Disease Control and Prevention (CDC) from launching a new media campaign, “Treatment Works,” that heartily encourages people with HIV to get in care and start treatment, and also to remain in care and adhere to ARV regimens. This is no doubt a worthy goal, especially because of concerns over what’s known as the care continuum or the treatment cascade. Of all Americans diagnosed with HIV, only an estimated 77 percent have been linked to care, 51 percent have stayed in care, 46 percent are on treatment, and a mere 35 percent have an undetectable viral load.
However, some activists are concerned that the CDC campaign doesn’t qualify its message about the importance of treatment with an acknowledgement that researchers are still searching for incontrovertible evidence of early treatment’s net benefits.

Sean Strub, an ACT-UP veteran who is the founder and former publisher of POZ,wrote that the CDC is waging a campaign for people with HIV to begin treatment immediately that’s based not only on shaky research but on a larger public health goal, Strub also wrote on his listserv email that such a subjugation of individual health decisions “is unethical, a violation of the autonomy of people with HIV and of human rights. History will not look kindly on this announcement.”as there is no a net benefit of early versus delayed treatment..
But CDC quote many studies which suggest that starting ARVs in the 350 to 500 range reduces the progression of HIV disease, although they haven’t shown whether it also reduces risk of death.When it comes to the 500 CD4 divide, HHS states that the agency can only make a moderate recommendation, one supported merely by “expert opinion,” to begin treatment before crossing that point. 
The NA-ACCORD study found that delaying until CD4s fell below 500 raised the risk of death by 94 percent when compared with starting above 500 CD4s. On the other hand, an analysis of the ART-CC cohort found that there was no significant difference in the risk of death between starting treatment at 451 to 550 CD4s and starting at 351 to 450 CD4s. And in the CASCADE Collaboration, those who began ARVs with between 500 and 799 CD4s did not benefit from a significant reduction in the progression to AIDS or death.
Adding a new dimension the to debate are the 2011 results of the HPTN 052 trial, which found that starting ARVs (regardless of CD4 count) reduces the risk of transmitting HIV among heterosexual mixed-HIV status partners by 96 percent. Even more dramatically, the PARTNER study’s interim results, released in March 2014, suggest that maintaining an undetectable viral load through ARV treatment may virtually eliminate the chance of transmitting the virus to others.
Consequently, the February 2013 revision of the HHS treatment guidelines added the potential for reducing transmission risk as one of the factors to weigh when deciding on a start point for treatment.

While activists have rallied behind this new promise that “treatment as prevention” (TasP) may help shrink the HIV epidemic, many also maintain concerns that individual liberties are being subverted to larger public health objectives. They worry that doctors may be less likely to consider any significant drawbacks to submitting a patient with a high CD4 count to treatment toxicities when the clinician has the goal of lowering the so-called “community viral load.”