In Reply: Dr Zirulnik raises a point that can affect not only the timing of when to start antiretroviral therapy, but the definition of symptomatic HIV infection. Since our first report was published in 1996,1 the International AIDS Society–USA Antiretroviral Guidelines Panel has consistently recommended beginning therapy in the setting of symptomatic HIV disease. However, at that time, symptomatic disease was seen more narrowly (AIDS-defining opportunistic diseases; recurrent mucosal candidiasis; oral hairy leukoplakia; and chronic unexplained fever, night sweats, and weight loss). It is now recognized that symptoms and signs of uncontrolled HIV replication, such as subtle neurocognitive changes, exist even at higher CD4 cell counts.2,3 Although HIV encephalopathy and dementia would be classified as “classic” symptomatic disease triggering initiation of therapy, confirmed subtle neurocognitive changes should also be included in the definition of symptomatic HIV disease, and therapy would be warranted. Before attributing symptoms and signs to HIV, careful evaluation should exclude other treatable causes such as depression and substance abuse.
Thompson MA, Hammer SM. Therapy Recommendations for HIV-Associated Neurocognitive Disorders—Reply. JAMA. 2008;300(21):2482-2483. doi:10.1001/jama.2008.734