tailieunhanh - HIV Medicine - part 3

Không phản ứng nghịch để đạt được mỗi một trong các mục tiêu điều trị lâm sàng, miễn dịch và virus học - được gọi như là một phản ứng nghịch. Một số bệnh nhân có thể điều trị thành công virus học mà không có cải thiện miễn dịch, tiếp tục có một lượng tế bào CD4 rất thấp + tế bào T-đếm mặc dù nồng độ virus không thể phát hiện | 4. Goals and principles of therapy 167 Discordant response Failure to achieve every one of the therapeutic goals - clinical immunological and virological - is referred to as a discordant response. Some patients may have virological treatment success without immunological improvement continuing to have a very low CD4 T-cell count despite undetectable viral load Piketty 1998 Renaud 1999 Gabrar 2000 Piketty 2001 . In addition to age the risk factors for a lack of immunological treatment response despite good viral suppression include low CD4 T-cell counts at baseline as well as having a low viral load at the start of treatment Florence 2003 Kaufmann 2005 . In older patients immunological response is often only moderate in comparison to virologi-cal response. Various studies have demonstrated that the probability of not achieving a rise in CD4 T-cell count increases with patient age and with progressive decrease in thymus size as detected by CT Goetz 2001 Marimoutou 2001 Piketty 2001 Teixera 2001 Viard 2001 . Patients who are intravenous drug users also have relatively poor increases in CD4 T-cells compared to other patients Dragstedt 2004 . Other possible causes for a lack of immunological response despite good viral suppression may be immuno- or myelosuppressive concomitant therapies. Conversely HAART may be extremely effective immunologically and induce significant increases in the CD4 T-cell count while viral load remains detectable. This can sometimes be observed in children and adolescents see Pediatrics chapter . The frequencies of such discordant responses in adults are outlined in the table below. Table Prospective cohort studies treatment response Response to HAART Piketty 2001 Grabar 2000 n 42 n 2236 Virological and immunological response Discordant only immunological response Discordant only virological response No treatment response 60 48 19 19 9 17 12 16 Immunological response rise in CD4 T-cells 100 pl after 30 months Piketty 2001 or 50 pl after 6 .