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Sunday, November 12, 2017

Guidelines are fooling you

This was originally published here, in French. We provide this translation for your convenience, practical aspects may differ where you live.

Treat-Early: How Guidelines are misleading

By Charles-Edouard!

The doctor does not analyze the ASAT / ALAT for fun! The liver is on the front line and receives the most of toxicity! If allowed to, toxicity sets in and becomes irreversible; and if we do not want to let it do, what do we do ?! Overprescription is a real martyrisation of women's body. You were asymptomatic and immunocompetent, and, abracadabra! You're hepato-deficient ... Bravo!

Treat early! Without treating better ???

Updates of the Morlat Report [aka French Guidelines] are published here. The most recent discuss initiation of a first antiretroviral treatment (October 2017). We will discuss here what is on page 4.
Morlat ANRS vih HIV OMS IAS EACS recommendations
Short reminder: the question is to know at how many CD4 it is recommanded to initiate treatment. Before it was less than 200, then they extended the indication to less than 350 and less than 500, then, now, less I-do-not-know-what: everyone is concerned. In a review (Should HIV therapy be started at a CD4 cell count above 350 cells / μl in asymptomatic HIV-1-infected patients?), C. Sabin showed that, in the area with very low risk, studies were indecisive (this which is hardly surprising when the absolute risk is so low). She asserted that only a comparative, randomized, trial would make it possible to decide. She considers that the START trial fulfills this role. Legitimate hope if the trial had not been, by construction, biased. The START scandal is multi-faceted: it will be our summer 2018 series! So we are not going at it here: just remember that this trial is biased, by construction.

The Morlat Report concludes in favor of undifferentiated, early treatment.

Treat early? Bullshit! Shouts the European cohort

The most recent study, the HIV-CAUSAL cohort, under our tropics, concludes to the futility of treat-early. Nobody ever mentions toxicity, obviously ... In Europe, in the area of minimal risk, the individual balance between individual clinical benefit and medico-pharmaco-induced toxicity (), is not at all in favor of treat-early. As a proof, read this case, of a patient, deceased, horribly, due to pharmaco-toxicity, in 2009.

They conclude: the beneficial effect is less than in recent randomized trials. In fact it is zero: 5j. of additionnal life in expectancy! However, in its latest version, the Morlat report omits, shamelessly, this mega-study (55,000 patients!), published in The Lancet HIV(2015). Maybe they do not read the LANCET HIV...

How did we get there?

To bias START, they surreptitiously introduced patients at high risk (pretreatment) among others, at microscopic risk. They are necessarily tipping the scales towards early treatment.

Morlat, using, as justification, the ANRS-TEMPRANO trial pushes it one step further: we will use patients from a geographical area (Senegal) with high endemicity of tuberculosis. Tuberculosis, or even its suspicion, is an indication for prophylactic antituberculosis treatment: Tuberculosis greatly raises the risk. How do we know that? Exactly thanks to the trial ... ANRS-TEMPRANO! Adding insult to injury!

The trial demonstrates the benefits of antituberculosis prophylaxis. And they would like us to believe that they recruited HIV patients at very, very low risk! It's amazing when you think about it!

Actors of TEMPRANO write an article, and, in very civilized terms (they work for ... ANRS ...), give the keys to this incredible trickery (trickery for the French, for the Senegalese, unfortunately, this is real).

The article: Antiretroviral treatment regardless of CD4 count: the universal answer to a contextual question. It reads: [...] This difference is mainly due to the geographical context of morbidity. [...] [the benefit] is especially true in low-resource settings where TB and other bacterial diseases are highly prevalent.

Morlat ANRS vih HIV OMS IAS EACS recommendations

This is a disputed benefit, probably zero. If this is all the more beneficial in areas of high prevalence (TB, etc.), it is therefore, on the contrary, much less beneficial in low prevalence areas. From their point of view (Senegal), the authors welcome a universal recommendation, while warning us that, in the North, this benefit is probably illusory.
TEMPRANO Morlat ANRS tuberculose vih HIV AIDS TB

Of 40 million infected, 2 live in the North. For 95% (the South) an indication extension is beneficial, while it is zero (or even negative) for the 5% that we are. In misleadingly mixing two very different health risk populations, in proportion 95% - 5%, it is obvious that the decision, taken on the average of this amalgam, is actually detrimental to us. To illustrate that , I propose to take the TEMPRANO table, and subtract tuberculosis and invasive bacteria events, if you consider that it is a risk to which you are not exposed. The TREMPANO table also indicates that tuberculosis-disease has caused the death of 8 patients (estimated) (you are told that these are patients at very very low risk ...).

Event Differed Treatment Early Treatment
Tuberculosis57 28
Invasive Bacteries 42 14
Other10 6
Deaths (*)26 21
Total 135 69
Let's remove what is endemic there (Tuberculosis and invasive bacteries )
Corrected Deaths (*)20 19
Corrected Total 30 25

(*) You will notice, by the way, that they have counted patients twice: the tuberculosis, and the death that follows! (But that does not shock anyone!) We will also remove these deaths proportionally (for lack of better). There are 8 deaths (5 + 3) attributed to tuberculosis at the 57:27 ratio, ie 2: 1, so 6: 2. I spare you the calculation of small p, the risk, if any, small, with an absolute risk, very small (we are in Senegal ... Not in Pithiviers)

The average French patient, never exposed to the risk of tuberculosis bacillus and other endemic bacteria is at zero risk. The young person, without particular comorbidity, without significant immunodepression will be inflicted a triple therapy, daily, over a dozen years in excess, to avoid, hold your breath: the Senegalese tuberculosis!

Treat early: an ICCARRE booster

Think what you want, even say that they do not care a damm, you can't do anything: indeed the Morlat group, unlike the HAS, is not justiciable: you can't sue them! (HAS you can ...); the HAS remains on the 350 threshold...

My doctor, once confessed to me, long after, that he has never seen any PCP or Kaposi at 500!

This leads to ostracism towards patients-who-are-not-fooled: they are quickly excluded! Yet, if we had told them about ICCARRE, 1/7 ... Treat-early, if accompanied by Treat-better is more attractive.

We will see the economic, societal, liberticidal, coercive, toxic consequences in a future post ...

Feel free to comment, to like to share and to use

Have a good Weekend, good fuck and do not abuse of meds/drugs

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