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Medical Forum / Diseases and Disorders / AIDS / January 2006HIV and TB
http://www.guardian.co.uk/aids/story/0,,1669460,00.html South Africa's townships battle double trouble MSF clinics are pioneering new treatments to tackle the deadly link between HIV and TB Chris McGreal Saturday December 17, 2005, Guardian The disease is not new and neither is the cure. This poses a problem for the doctors of Khayelitsha. The means of diagnosing tuberculosis was established long ago, and the rigid regime of drug treatment that once led to predictions of its eventual eradication has been in place for 40 years. But in Khayelitsha township, near Cape Town, rampant HIV/Aids is not only driving a TB epidemic but distorting the disease so that it bears only a faint resemblance to that which blighted developed countries until the 1950s. "TB is a different disease now," said Peter Saranchuk, a doctor at the Médecins sans Frontières clinic in Khayelitsha. "Twenty years ago, it was mainly of the lungs and you could diagnose it from a cough. Aids has changed that. If someone is HIV-positive, they're more likely to get TB in other parts of the body. It constantly amazes me the places you can get TB in. There's abdominal TB, TB meningitis, TB of the breast, TB of the kidneys. It can hit you anywhere between your feet and your brain. This is a new phenomenon." Khayelitsha sits at the heart of a worldwide TB epidemic that has hit South Africa hard. The level of infection in the township is now four times that at which the World Health Organisation declares a medical crisis, and is continuing to rise. But ask about tuberculosis on the streets of Khayelitsha, and almost everyone jumps to the same conclusion: what you are really talking about is Aids. TB is the single largest killer of people with Aids."TB and HIV are double trouble," said Dr Saranchuk. "The chances are that if you're being treated for TB then you have HIV. One person with HIV has a 10% chance every year of getting TB because of the living conditions. People live on top of each other in shacks. If one person is coughing, everyone is affected." Nozyoho Wana, who has two children, takes 22 pills daily, at four different times, to treat HIV and the TB that almost killed her. She was diagnosed when she fell so sick that she had to be carried to hospital. Her CD4 count - an indicator of the immune system's strength - was 31. The WHO recommends antiretroviral treatment for Aids when the CD4 count falls below 200. "I was really lucky because I was really sick. I had piles and I couldn't go to the toilet, and I had sores on my feet and I couldn't walk," she said. "I thought it was Aids, but I had no idea I had TB. "Now I'm being treated for both. I have to take pills in the morning and evening and come to the clinic every day. They tell me that if I do not stick exactly to the programme I will die." Once Ms Wana was established on the antiretrovirals, she was permitted to take a fortnight's supply of drugs home. But treatment for TB is traditionally much more rigid. The WHO insists that patients are closely monitored to ensure they take their drugs precisely on time by attending a clinic each day. But MSF is treating more than 2,000 patients for TB and Aids at its Ubuntu clinic in Khayelitsha, and says there are not enough doctors and nurses to see the rising number of patients every day. Dr Saranchuk says the problems of TB are compounded by the means of diagnosis, which takes six weeks to produce a result. "Our problem is that we are treating TB with tools developed 40 years ago for a very different kind of disease, and with drug regimes that were never designed for dealing with this scale of infection or for people who are also combating another major disease," he said. MSF established the Ubuntu clinic - the name means "togetherness" - as the first in South Africa where patients see a single doctor for both TB and HIV. "We had to construct it in the face of many political obstacles," said Eric Goemaere, head of the MSF operation in the township. He is no stranger to political controversy. He opened the first clinic to provide anti-Aids drugs in South Africa in defiance of opposition from President Thabo Mbeki. But the issue of treating TB is a fraught one. MSF wants to train nurses to take on the role of doctors in monitoring patients, and to ease the rigid monitoring of those people with a proven track record of taking drugs for HIV. It says the long waits at clinics each day for people trying to keep a job and look after a family are a major reason for dropout, particularly after the first month when TB symptoms disappear. "The TB culture is the Stalinist public health culture," said Dr Goemaere. "It is completely standardised. In the HIV culture, it is patient-centred, aimed at helping the individual. The TB world is not interested in the individual patient. It is interested in stopping transmission and the spread of the disease. We have to change this or we are never going to be able to cope with this disease." __________________________________________________________________ Kate Evans U.S. Coordinator, Campaign for Access to Essential Medicines Doctors Without Borders/Médecins Sans Frontières (MSF) > http://www.guardian.co.uk/aids/story/0,,1669460,00.html > > South Africa's townships battle double trouble > "TB is a different disease now," > TB is the single largest killer of people with Aids." An unqualified statement leads one to reconsider what reporters actually mean when they refer to their work as a "story". > The WHO recommends antiretroviral treatment for Aids when > the CD4 count falls below 200. My how treatment has changed from those heady days of 1996 when the aggressive use of the protease inhibitor cocktails was advocated in a "hit hard and hit early" strategy, NOT for people merely with fewer than 200 CD4s, but as a method to target this silly virus. Gee, George - both YOU and Gary Stein and Bennett and Carlton Hogan and so many others were carrying the pharma banner on this newsgroup for that deadly strategy. Aren't you even the least bit sorry? susie >My how treatment has changed from those heady days of >1996 when the aggressive use of the protease inhibitor cocktails [quoted text clipped - 7 lines] > >Aren't you even the least bit sorry? Not at all! Indeed, what you are stating is a dead cold lie. I have opposed the notion of "hit hard, hit early" from the moment Ho came out with it. I rejected the "tap and drain" model as simplistic. Indeed, I think starting ARV should happen somewhere between 200 and 350, depending on other factors like clinical condition, viral load, rate of T cell decline, readiness of the person to do so, etc. I defy you to produce any comment where I supported "hit hard, hit early." George M. Carter >>My how treatment has changed from those heady days of >>1996 when the aggressive use of the protease inhibitor cocktails [quoted text clipped - 11 lines] > opposed the notion of "hit hard, hit early" from the moment Ho came > out with it. Oh, my, speaking of lies... now that you know the truth, you run and hide. How cowardly. > Indeed, I think starting ARV should happen somewhere between 200 and > 350, depending on other factors like clinical condition, viral load, > rate of T cell decline, readiness of the person to do so, etc. Well thar ya go! Sheesh ... make up your silly-assed mind already! You advocate HIT HARD AND HIT EARLY - that's NOT the standard of care today, as you well know!!! Of course, all can plainly see that you and the Pharma Shill Family have always played fast-and-loose with the definition of the word "early" (sorta like Clinton's claim that a blow job is not a sexual relation, but that's for another post). > I defy you to produce any comment where I supported "hit hard, hit > early." Defy? LOL!!! Thank YOU for generously providing precisely that, so let's review, shall we? susie ========== Early ARV Treatment = NO BENEFIT After years of promoting "early ARV" treatment as "life-saving", the pharma shills on this newsgroup are STILL biting their tongues over the July 2004 revision of the HIV Standard of Care as published in JAMA: "For less severely compromised individuals (ie, asymptomatic individuals with CD4 cell counts > 200/microL), there are no definitive data from prospective, randomized controlled studies to determine when antiretroviral therapy is associated with a survival benefit." My favorite parts are the disclosures about the outrageous conflicts of interest by the doctors who have been misleading about HIV treatment since the first AZT studies. ____ In the 7/14/04 JAMA article titled "Treatment for Adult HIV Infection: 2004 Recommendations of the International AIDS Society-USA Panel," Yeni et al. state: "Randomized clinical trials have demonstrated a survival benefit with the use of antiretroviral therapy by patients with severe immunodeficiency. For less severely compromised individuals (ie, asymptomatic individuals with CD4 cell counts > 200/microL), there are no definitive data from prospective, randomized controlled studies to determine when antiretroviral therapy is associated with a survival benefit. In the absence of such data, the decision to initiate therapy should be made based on survival and disease progression information obtained from observational studies, the consequences of moderate degrees of immune deficiency, and the long-term safety of antiretroviral drugs." --------------------------------- JAMA.2004 Jul 14;292:251-265. Treatment for Adult HIV Infection 2004 Recommendations of the International AIDS Society-USA Panel Patrick G. Yeni, MD; Scott M. Hammer, MD; Martin S. Hirsch, MD; Michael S. Saag, MD; Mauro Schechter, MD, PhD; Charles C. J. Carpenter, MD; Margaret A. Fischl, MD; Jose M. Gatell, MD, PhD; Brian G. Gazzard, MA, MD; Donna M. Jacobsen, BS; David A. Katzenstein, MD; Julio S. G. Montaner, MD; Douglas D. Richman, MD; Robert T. Schooley, MD; Melanie A. Thompson, MD; Stefano Vella, MD; Paul A. Volberding, MD Abstract: Context Substantial changes in the field of human immunodeficiency virus (HIV) treatment have occurred in the last 2 years, prompting revision of the guidelines for antiretroviral management of adults with established HIV infection. Objective To update recommendations for physicians who provide HIV care regarding when to start antiretroviral therapy, what drugs to start with, when to change drug regimens, and what drug regimens to switch to after therapy fails. Data Sources Evidence was identified and reviewed by a 16-member noncompensated panel of physicians with expertise in HIV-related basic science and clinical research, antiretroviral therapy, and HIV patient care. The panel was designed to have broad US and international representation for areas with adequate access to antiretroviral management. Study Selection Evidence considered included published basic science, clinical research, and epidemiological data (identified by experts in the field or extracted through MEDLINE searches using terms relevant to antiretroviral therapy) and abstracts from HIV-oriented scientific conferences between July 2002 and May 2004. Data Extraction Data were reviewed to identify any information that might change previous guidelines. Based on panel discussion, guidelines were drafted by a writing committee and discussed by the panel until consensus was reached. Data Synthesis Four antiretroviral drugs recently have been made available and have broadened the options for initial and subsequent regimens. New data allow more definitive recommendations for specific drugs or regimens to include or avoid, particularly with regard to initial therapy. Recommendations are rated according to 7 evidence categories, ranging from I (data from prospective randomized clinical trials) to VII (expert opinion of the panel). Conclusion Further insights into the roles of drug toxic effects, drug resistance, and pharmacological interactions have resulted in additional guidance for strategic approaches to antiretroviral management. Author Affiliations: Department of Infectious Diseases, Hospital Bichat-Claude Bernard, X. Bichat Medical School, Paris, France (Dr Yeni); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (Dr Hammer); Department of Immunology and Infectious Diseases, Harvard Medical School, Boston, Mass (Dr Hirsch); Department of Medicine, University of Alabama, Birmingham (Dr Saag); Department of Preventive Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil (Dr Schechter); Department of Biomedicine, Brown University School of Medicine, Providence, RI (Dr Carpenter); Department of Medicine, University of Miami School of Medicine, Miami, Fla (Dr Fischl); Department of Medicine, University of Barcelona, Barcelona, Spain (Dr Gatell); Department of HIV Medicine, Chelsea and Westminster Hospital, London, England (Dr Gazzard); International AIDS Society-USA, San Francisco, Calif (Ms Jacobsen); Department of Medicine, Stanford University Medical Center, Stanford, Calif (Dr Katzenstein); Department of Medicine, University of British Columbia, Vancouver (Dr Montaner); Departments of Pathology and Medicine, University of California and San Diego VA Healthcare System, San Diego (Dr Richman); Department of Medicine, University of Colorado School of Medicine, Denver (Dr Schooley); AIDS Research Consortium of Atlanta, Ga (Dr Thompson); Istituto Superiore di Sanità, Rome, Italy (Dr Vella); Department of Medicine, University of California and San Francisco Veterans Affairs Medical Center, San Francisco (Dr Volberding). =================================================== Financial disclosures of AIDS researchers - 7/14/04 JAMA JAMA, July 14, 2004 Vol 292, No. 2 251-265 Treatment for Adult 2004 Recommendations International AIDS Society- USA Panel Patrick G. Yeni, MD Scott M. Hammer, MD Martin S. Hirsch, MD Michael S. Saag, MD Mauro Schechter, MD, PhD Charles C. J. Carpenter, MD Margaret A. Fischl, MD Jose M. Gatell, MD, PhD Brian G. Gazzard, MA, MD Donna M. Jacobsen, BS David A. Katzenstein, MD Julio S. G. Montaner, MD Douglas D. Richman, MD Robert T. Schooley, MD Melanie A. Thompson, MD Stefano Vella, MD Paul A. Volberding, MD Patrick G. Yeni, MD Dr Yeni has received research grants for site investigator from GlaxoSmithKline, Bristol- Myers Squibb, Boehringer Ingelheim, Roche, Tibotec/Virco, and Gilead. Dr Yeni has received honoraria for advisory positions and lecture sponsorships from Abbott Laboratories, Bristol-Myers Squibb, Boehringer Ingelheim, Roche, Tibotec/Virco, and Merck Sharp and Dohme. Scott M. Hammer, MD Dr Hammer has received research grants for site investigator from Roche, GlaxoSmithKline, and Merck. Dr Hammer has been a consultant for Bristol-Myers Squibb, GlaxoSmithKline, Merck, Shionogi, Pfizer, Boehringer Ingelheim, Shire, Gilead, and Tibotec/ Virco. Martin S. Hirsch, MD Dr Hirsch has received research support from Takeda. Dr Hirsch has been a consultant for Schering Plough, GlaxoSmithKline, and Bristol-Myers Squibb. Michael S. Saag, MD Dr Saag has received research support from Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Ortho Biotech/Johnson&Johnson, Pfizer/Agouron, and Hoffmann- LaRoche. Dr Saag has been a consultant for Abbott Laboratories, Boeringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, OrthoBiotech/Johnson & Johnson, Pfizer/Agouron, Roche, Schering-Plough, Shire Pharmaceutical, TherapyEdge, Tibotec/ Virco, Trimeria, Vertex, and ViroLogic. Dr Saag has received honoraria for positions on the speakers bureau for Abbott Laboratories, Boeringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, OrthoBiotech, Johnson & Johnson, Pfizer, Agouron, Roche, Schering-Plough, Shire Pharmaceutical, TherapyEdge, Tibotec/Virco, Trimeria, Vertex, and ViroLogic. Margaret A. Fischl, MD Dr Fischl has received research grants from Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, and Ortho Biotech. Dr Fischl has received honoraria for continuing medical education programs from GlaxoSmithKline. Dr Fischl has served as an advisor for Agouron Pharmaceuticals and GlaxoSmithKline. Brian G. Gazzard, MA, MD Dr Gazzard has received research grants from Abbott Laboratories, Boehringer Ingelheim, Pfizer, GlaxoSmithKline, Bristol-Myers Squibb, and Johnson &Johnson. Julio S. G. Montaner, MD Dr Montaner has received grants from Abbott Laboratories, Agouron Pharmaceuticals, Shire Biochemical, Boehringer Ingelheim, Bristol-Myers Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Roche, Kucera Pharmaceutical, Merck Frosst Laboratories, Pharmacia & Upjohn, and Trimeris. Dr Montaner has received honoraria for speaking from Abbott Laboratories, Agouron Pharmaceuticals, Shire Biochemical, Boehringer Ingelheim, Bristol-Myers Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Kucera Pharmaceutical, Merck Frosst Laboratories, Pharmacia & Upjohn, and Trimeris Inc. Dr Montaner holds 2 US patents, one regarding use of nevirapine and another regarding pharmacological applications of mitochondrial DNA assays. Dr Montaner has 2 patent applications that are pending, one regarding pharmacological applications of mitochondrial DNA assays and another regarding sepsis. Robert T. Schooley, MD Dr Schooley has received grants from GlaxoSmithKline, Bristol-Myers Squibb, Merck, and Tibotec/Virco. Dr Schooley has been a consultant for Abbott Laboratories, Pfizer, Hoffmann-LaRoche, GlaxoSmithKline, BristolMyers Squibb, Merck, Vertex, ViroLogic, and Tibotec/Virco. Melanie A. Thompson, MD Dr Thompson has received grants from Abbott Laboratories, Agouron/ Pfizer Pharmaceuticals, Boeringer Ingelheim, Bristol-Myers Squibb, Chiron Corporation, GlaxoSmithKline, Gilead Sciences, Merck Research Laboratories, Oxo-Chemie, Roche, Serono, Theratechnologies, Triangle Pharmaceuticals, Trimeris, and VaxGen. Dr Thompson has been a consultant for Abbott Laboratories, Agouron/Pfizer Pharmaceuticals, GlaxoSmithKline, Gilead Sciences, Serono, and Triangle Pharmaceuticals. Dr Thompson has received honoraria for lecture sponsorships and continuing medical education from Abbott Laboratories, Agouron/ Pfizer Pharmaceuticals, Boeringer Ingleheim, Bristol-Myers Squibb, GlaxoSmithKline, Gilead Sciences, Roche, Serono, Triangle Pharmaceuticals, and Trimeris. Mauro Schechter, MD, PhD Dr Schechter has received honoraria from Abbott Laboratories, Bristol-Myers Squibb, GlaxoSmithKline, Merck, and Roche. Dr Schechter has been a consultant for Abbott Laboratories, BristolMyers Squibb, GlaxoSmithKline, Merck, and Roche. Jose M. Gatell, MD, PhD Dr Gatell has served in advisory positions for Roche, Bristol-Myers Squibb, Merck Sharp and Dohme, GlaxoSmithKline, Gilead, Boehringer Ingelheim, Abbott Laboratories, Tibotec/ Virco. Brian G. Gazzard, MA, MD Dr Gazzard has received lectureship fees from Abbott Laboratories, Boehringer Ingelheim, Pfizer, GlaxoSmithKline, Bristol-Myers Squibb, and Johnson & Johnson. David A. Katzenstein, MD Dr Katzenstein has held advisory positions at Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck, ViroLogic, Visible Genetics, and the Doris Duke Charitable Trust. Dr Katzenstein holds a US patent for polymerase chain reaction assays monitoring antiviral therapy and making therapeutic decisions in the treatment of AIDS. Stefano Vella, MD Dr Vella has received lecture sponsorship for satellite symposia and continuing medical education programs from Merck, Agouron, Gilead, Boehringer Ingelheim, and Roche. Paul A. Volberding, MD Dr Volberding has received honoraria from Gilead, Bristol-Myers Squibb, GlaxoSmithKline, and Boehringer Ingelheim. Dr Volberding has been a consultant for Pfizer, Bristol-Myers Squibb, and Shire. Douglas D. Richman, MD Dr Richman has been a consultant for Abbott Laboratories, Bristol-Myers Squibb, Chiron, Gilead, GlaxoSmithKline, Merck, Novirio, Pfizer, Roche, Takeda, Triangle, and ViroLogic. Corresponding Author: Patrick G. Yeni, MD, Hospital Bichat-Claude Bernard, 46 Rue Henri-Huchard, 75877 Paris Cedex 18, France (Patrick.Yeni@Bch .Ap-Hop-Paris.Fr). >Oh, my, speaking of lies... now that you know the truth, >you run and hide. Not at all, dearie. >How cowardly. I'm right here. >> Indeed, I think starting ARV should happen somewhere between 200 and >> 350, depending on other factors like clinical condition, viral load, [quoted text clipped - 3 lines] > >Sheesh ... make up your silly-assed mind already! A mind should not be so inflexible it cannot change--that would be simply stupid. However, with regard to this, I do not advocate and have never advocated hit hard hit early. >You advocate HIT HARD AND HIT EARLY - You may say that but it is not true. Having corrected you, now you are simply lying. >> I defy you to produce any comment where I supported "hit hard, hit >> early." [quoted text clipped - 3 lines] >Thank YOU for generously providing precisely that, so let's review, >shall we? Your review did not support your contention that I supported "hit hard, hit early." You did note merely that others have stated: "For less severely compromised individuals (ie, asymptomatic individuals with CD4 cell counts > 200/microL), there are no definitive data from prospective, randomized controlled studies to determine when antiretroviral therapy is associated with a survival benefit." I agree with this. But there is considerable evidence that waiting TOO long is a bad idea--it is more difficult and survival can be impaired if there is a nadir CD4 count below 100 or 50. I've still got numerous friends alive (doing ARV therapy almost all, sometimes with breaks) who have had such low nadirs--but many folks have not survived. Starting too early, by contrast, risks increased problems with cost, resistance and side effects and toxicities. The standards (which you never seemed to quite care about before) are nicely articulated here: http://www.medscape.com/viewarticle/410363 from that article, I'd say my thoughts are more in line with BHIVA: "Both the International AIDS Society-USA (IAS-USA) and the British HIV Association (BHIVA) guidelines provide a somewhat less aggressive approach in asymptomatic patients than do the DHHS guidelines. Broadly, the IAS-USA guidelines state that clinicians should recommend antiretroviral therapy if the CD4+ cell count is (1) below 350/µL; (2) between 350 and 500/µL with a viral load above 5000 copies/mL; or (3) above 500/µL with a viral load above 30,000 copies/mL.[2] The BHIVA guidelines, as expected, are the most liberal and recommend that clinicians start antiretroviral treatment in asymptomatic patients with a CD4+ cell count below 350/mL but that they may consider deferring therapy in patients with a CD4+ cell count between 350 and 500/µL and a viral load above 30,000 copies/mL.[3]" Another way to assess when to start is looking at the CD4 percentage: http://www.aidsmap.com/en/news/F731C054-1B9C-4A8B-BB54-052E27C113DE.asp So, Freddy-Sue....next? George M. Carter >>> Indeed, I think starting ARV should happen somewhere between 200 and >>> 350, depending on other factors like clinical condition, viral load, [quoted text clipped - 6 lines] > A mind should not be so inflexible it cannot change--that would be > simply stupid. Well, that about sums it up for ya. > However, with regard to this, I do not advocate and > have never advocated hit hard hit early. You just did, dipshit. >>You advocate HIT HARD AND HIT EARLY - > > You may say that but it is not true. It IS true - your own statement proves it! > you are simply lying. LOL! You are the liar here. >>> I defy you to produce any comment where I supported "hit hard, hit >>> early." [quoted text clipped - 15 lines] > I agree with this. But there is considerable evidence that waiting TOO > long is a bad idea So you DO advocate hit early and hit hard. Sorry, missy, you don't get it both ways... susie >So you DO advocate hit early and hit hard. Nope. People with over 500 CD4 cells almost never need ARV. Some data suggest there may be benefit that outweighs the cost, risk of resistance and toxicity. But I'm not convinced by it. Other data flatly contradict the notion. George M. Carter >>So you DO advocate hit early and hit hard. > > Nope. People with over 500 CD4 cells almost never need ARV. Oh, thank God George M Carter has so decreed what is healthy and what is NOT... LOL!!! George Mary-Bob, you are SOOO full of sh.t... susie >>>So you DO advocate hit early and hit hard. >> >> Nope. People with over 500 CD4 cells almost never need ARV. > >Oh, thank God George M Carter has so decreed >what is healthy and what is NOT... Oh--so NOW you ARE in favor of hit hard hit early? You are stating quite clearly here that you believe people with OVER 500 CD4 cells need ARV? PHARMA PIMP!! >>>>So you DO advocate hit early and hit hard. >>> [quoted text clipped - 4 lines] > > Oh--so NOW you ARE in favor of hit hard hit early? So you're back on the bottle again, eh George Mary-Bob? susie >So you're back on the bottle again, eh George Mary-Bob? Nope. Don't really drink. Do you, Frodlet-Susie-poops? Mary xmas >>So you're back on the bottle again, eh George Mary-Bob? > > Nope. Don't really drink. Still shooting heroin? susie >> http://www.guardian.co.uk/aids/story/0,,1669460,00.html >> [quoted text clipped - 22 lines] > > Aren't you even the least bit sorry? No because none of us ever advocated Ho's strategy. If you do a Google Groups search you will find that we always said ARV need not start before CD4 cells dropped to between 350 and 200. Now you might find some statements saying if an individual patient choose to start earlier that was there free choice to do so, but there was no evidence showing any proven benefit from starting early. If your clouded mind can remember that far back you would remember that Bennett being trained in the UK and would have followed the UK guidelines which have always been more conservative about when to start ARV then has been the US guidelines. Gary Stein >>> http://www.guardian.co.uk/aids/story/0,,1669460,00.html >>> [quoted text clipped - 26 lines] > Groups search you will find that we always said ARV need not start before > CD4 cells dropped to between 350 and 200. B-U-L-L-S-H-I-T Every single one of you PharmaKillers went hook-line-sinker for the Ho Plan. You lie. You killed. You aren't sorry. susie |
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