A few short items.

First: I was privileged to see Leonard Cohen in concert on Monday night. I am late to the cult (and it is very cultish) Leonard Cohen thing- turned on to his music by my friend David, who downloaded some of his music on my computer years back, which ended up on my iPod- and I ended up a fan.

Music is as close as I get to going to church. My favorite moment of the night was the song, Anthem. The chorus goes:

Ring the bells that still can ring

Forget your perfect offering

There is a crack in everything

That’s how the light gets in.

Speaks volumes.

Next: there have been a couple of comments from religious folks about my post on confirmational bias. I try and maintain some sense of equipoise when dealing with religion or spirituality- and sometimes it is difficult. These post boil down to, ’God is real, you are going to hell if you don’t believe what I believe. End of story.

Well I am (not really) sorry. For me,  that isn’t good enough. It is never enough to simply state that something is- if you believe something, make your case, convince me, explain yourself.

That is why I like the scientific method, which is founded on the idea of questioning and testing what you believe to be true. I simply do not have time for any set of beliefs that does not test itself, does not challenge itself.

Last: There was a slightly off blurb in the New York Times science section which read:

Researchers have identified a new benchmark for starting drug treatment for AIDS, according to a report published online last week in the journal Lancet.

Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies (The Lancet)

The question of when to start therapy has been a “swinging pendulum,” notes an editorial accompanying the study. The marker in question is the CD4 count, which represents how many of the cells that the AIDS virus attacks are found in a microliter of blood.

In poor countries, the World Health Organization recommends starting when counts are anywhere from 200 to 350; in rich countries, the decision is made by patients and doctors. The new analysis, which looked at 18 studies with 45,000 American and European patients, concluded that starting earlier saved more lives, so treatment should begin when the count falls to 350.

It is a tradeoff. Aggressive early treatment may forestall full-blown AIDS and death, but antiretroviral drugs can cause fat redistribution, hepatitis, kidney failure, pain and elevated heart disease risk. Newer regimens are less toxic, but they are not always available in poor countries, where fewer than half of those who need drugs get them.

The finding has complex implications for Africa, where the number of people sick enough to need the drugs is increasing by about one million a year. If the W.H.O. adopts the new benchmark, the number could grow by another million, some estimate. Global donations to pay for treatment have not kept up with even today’s needs.

There are two problems with this little story. First, there is nothing new here. There has been evidence for some time that HIV treatment is more effective when started with CD4 counts above 350. That is what the DHHS guidelines recommend after all. Second, the ’tradeoff’ noted here is not wholly accurate. For example, the author states that ARVs can lead to an increased risk of heart disease. Fair enough, but not necessarily true in this context- being compared to later treatment. Untreated HIV also increases the risk of heart disease, and most of the research- particularly the research done more recently suggests the risk from untreated HIV is higher than the risk from drug side effects.