Thanks for your sage question.
This is one of the most challenging areas of HIV medicine- namely the pros and cons of antiretroviral therapy for persons with relatively high CD4 cell counts.
The article that you cite raises the point that with continuing CD4 cell depletion, there is very likely depletion of the very CD4 cells that recognize and therefore are responsible for attack of HIV-infected cells. This would raise the point that if one were to wait too long, the ability to reconstitute meaningful HIV-specific immunity wanes.
There is also recent information that suggests that the risk of certain kinds of malignancies appear to increase with lower CD4 cell nadirs. This coupled to recent data (Lichtenstein, 2002) from the HOPS cohort that suggest that the risk of new development of lipoatrophy is related to CD4 count nadir (less than 200)would seem to point out that there are HIV-related complications that may increase, the longer one waits to initiate therapy (or waits to reinitiate therapy).
Of course, the story is more complicated than just this. There is risk of other complications that relate to time on therapy, clearly the most significant (at least to me) is that of the developement of drug resistance. Adherence (or more importantly, risk of sub-optimal adherence) would be a strong factor in the decision to resume therapy or not. It is also very important that while on therapy, that you receive optimal counsel and monitoring about the therapy that you are on.
In the end analysis, I don't think that we have definative answers as to the best approach for every person. In the absence of proof of global risks and benefits, I'll provide the best possible counsel and defer to patient's desires (this operates under the premise of patient autonomy). For patients like you who are a motivated, very adherent patient, and understand the risks and potential benefits of resuming therapy, I would have little reason not to support that decision (indeed, I have several patients in my practice who have done exactly that).
I hope that this helps, good luck and stay in touch. BY
