When to start?

There is no set rule on when to start HIV treatments - if you feel generally lacking in energy, are suffering fevers, rashes or swollen glands you can consider HIV treatment at any CD4 count. However, you do not need to make any decisions straight away.

The answer to the question of ‘when to start’ varies according to the stage of your HIV disease or if there are special reasons for starting.

For people with recent HIV infection.

i.e. you had a recent seroconversion illness or you have had a recent positive HIV-test and had tested HIV negative in the previous 6 months

A number of smaller studies have suggested that a short course (3 months) of treatment for people with recent HIV infection could help the body’s immune system make a more effective response against HIV infection, stabilising the CD4 count to delay CD4 cell decline and the need to take treatments in the future.

Unfortunately there are no studies that strongly suggest any long-term benefit to early treatment. There is also evidence that people with recent HIV infection have higher levels of the HIV virus [1]A small infective organism which is incapable of reproducing outside a host cell. in their semen, thereby increasing the likelihood of sexual transmission of HIV. By treating people in the first few weeks of HIV infection, this could help reduce the risk of HIV transmission to sexual partners. As there are no current guidelines for treatment of HIV for people with recent HIV infection, and treatment is not recommended outside of participation within a clinical trial [2]A clinical trial is a research study to answer specific questions about vaccines or new therapies or new ways of using known treatments. Clinical trials are used to determine whether new drugs or treatments are both safe and effective. Carefully conducted clinical trials are the fastest and safest way to find treatments that work in people. Trials are in four phases: Phase I tests a new drug or treatment in a small group; Phase II expands the study to a larger group of people; Phase III expands the study to an even larger group of people; and Phase IV takes place after the drug or treatment has been licensed and marketed. , it is important that you speak with your doctor about the best options for you.

For people with chronic HIV infection who remain “well”

The current treatment guidelines (as of 2008) recommend treatment be offered whenever the CD4 cell count falls below 350. The pendulum is now swinging back towards earlier treatment of people who are well, and some experts would now recommend commencing treatment at CD4 counts about 350.

The viral load [3]A measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. is less important in determining when to start medication, but if the viral load is greater than 100,000 per ml, this might be another factor in starting treatment earlier rather than later. The goal of treatment is to prevent progression of HIV disease and the development of symptoms of HIV disease.

Currently, no clear long term benefits have been established for the commencement of HIV treatment for people who are well (i.e. do not have symptoms of HIV infection) and have CD4 counts above 350, although a number of studies do suggest that there may be some benefit in starting with a CD4 count between 350 and 500.

For people with a history of an AIDS defining illness, a CD4 count below 200 or severe symptoms of HIV disease regardless of CD4 count

Treatment is recommended for any person with symptoms of HIV disease—including neurological HIV disease—or have experienced an AIDS defining illness (opportunistic infection) in the past. The goal of treatment is both improvement in health and the prevention of further damage to the immune system or reoccurrence of an AIDS defining illness.

For women who are pregnant.

Here the goal of HIV antiviral [4]A medication or substance which is active against one or more viruses. May include anti-HIV drugs, but these are more accurately termed antiretrovirals. treatment is to reduce HIV viral load and therefore decrease the chances of vertical transmission from mother to baby.

Starting antiviral therapy is a serious commitment because it may mean taking treatments for the rest of your life. Taking treatments in the long term may affect your quality of life, particularly if you develop side effects or find daily pill taking burdensome. On the other hand, many people feel an improvement in their health and energy levels after starting antiviral therapy.

Any treatment decision needs to be discussed fully with your doctor, taking into account not only viral load and CD4 counts but most importantly, your ability to integrate combination therapy [5]Highly Active AntiRetroviral Therapy ??? aggressive treatment of HIV infection using several different drugs together. into the way you live.