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When should anti-HIV therapy be started?
There is no clear evidence on when is the best time for you to start taking anti-HIV drugs. This means that you must weight up with your doctor, on an individual basis, the likely benefits and risks of taking treatment now, as opposed to waiting until later. The current view is that treatment is clearly beneficial:
- If you have symptoms of HIV or AIDS.
- If you have a low CD4 count, another sign that the immune system is damaged.
BHIVA's recommendations about the timing of starting treatment depend upon your disease stage, meaning the length of time since you were infected, your CD4 count and the amount of HIV in your blood (viral load), and whether or not you have symptoms of HIV. These are summarised in Table 1 on the following page.
see table in PDF file
If you have contracted HIV very recently
The six month period which follows immediately after you contracted HIV is called primary infection. There is no proof that starting treatment at this time will definitely lead you to live a longer, healthier life.
Some doctors believe, however, that this time may offer a unique chance to intervene which may be lost later in infection as your immune system sustains ongoing damage, and so may be less able to respond to HIV itself.
This potential benefit has to be weighed against the risk of you getting side-effects, finding that treatment reduces your quality of life, and the possibility that if the treatment you take stops working effectively against HIV, you may be left with drug resistant virus.
A few people who took anti-HIV treatment very soon after infection seem to have maintained extremely low levels of HIV, even after stopping treatment. Others who have tried the same strategy have not had this response. Because there is a lack of clarity, it's recommended that if you do choose to take treatment in primary infection you join a clinical trial wherever possible.
Taking treatment at this stage may also be beneficial if your are experiencing a severe HIV seroconversion illness. It is not clear if you do start treatment at this time if you will have to continue to take it indefinitely. There is also the possibility that if you had symptoms they will come back if treatment is stopped.
If you have established (chronic) infection but not had HIV symptoms
Ideally, you should begin treatment before your CD4 count falls below 200. This is because if you start treatment when your CD4 count is below 200, you face a greater risk of ill health and even death, in the short-term, than if you start while your CD4 count is still above 200.
At higher CD4 counts, the picture is less clear. Most studies suggest that there seems to be no difference in the short-term risk of ill health if you begin treatment at CD4 counts above the 200 level. Therefore, the timing in these circumstances will depend on the level of your viral load, the speed at which your CD4 count is falling, the likelihood of you achieving good adherence to treatment, the presence of symptoms, the presence of hepatitis C virus coinfection and your wishes.
You may choose an earlier start, particularly if your CD4 count is falling by more than 80 cells per year, because this is likely to mean that the count will fall below 200 within the near future. Similarly, if you have a high viral load, and are not taking treatment, then you lose CD4 cells more quickly than others, and are at greater risk of illness or death in the short-term, and you may, therefore, choose to start treatment sooner.
You may wish to consider starting treatment earlier if you are also infected with hepatitis C virus (HCV), as liver disease becomes worse when the CD4 cell count is lower. The booklet HIV and hepatitis in this series has more information.
Delaying therapy reduces the impact of long-term side-effects and the development of drug resistance. Therapies of the future may be easier to take, less toxic and perhaps more effective against HIV. The best responses to anti-HIV treatment are generally seen with the first drug combination, so starting too early, or with the wrong drug combination may not be the best option.
If you are advised to start treatment but choose not to, then you should review your decision regularly and have your CD4 count and viral load monitored more frequently than usually recommended, for example every two months.
People with symptoms of HIV disease or AIDS
Everyone who has symptoms of HIV infection and has a CD4 count consistently below 200, or who has previously been diagnosed with AIDS or a severe or recurring HIV-related illness, should start treatment. If you have reached any of these points you have a high risk of opportunistic infections.
A possible exception, however, are people with tuberculosis (TB). There are potential interactions between anti-HIV drugs and a key medicine used to treat tuberculosis. Because of this, many doctors recommend delaying treatment with HAART until an individual has taken at least two months of tuberculosis treatment. Similarly, if you become ill with tuberculosis whilst taking HAART, you may be recommended to stop taking anti-HIV drugs for the first two months of tuberculosis treatment. There is a lot more information about this in the booklet, HIV and TB.