Strategies for first line HIV therapy

May 2008     View PDF     En español

When to start therapy

It’s possible and reasonable to start HIV drugs at any point in the course of your HIV disease. This is true even if you didn’t find out you have HIV until you became ill. Although there’s no agreement on the best time to start, it’s never too late to start and benefit from therapy.

To help guide people with their treatment decisions, a group of researchers, doctors, people living with HIV, and their advocates regularly meet to discuss the results of studies and their experiences treating and living with HIV. This group is called the Federal Guidelines Panel, and every year or so they update the “Federal Guidelines” or more simply “Guidelines.” The excerpts below are for adults and adolescents.

These Guidelines are meant to help guide people through the issues that may arise while using therapy, including when and what to start. They’re not absolute rules. When enough information is known about some aspect of treating HIV disease, the Guidelines will recommend or suggest a preference. When data are less clear, they will state just that.

Basic federal recommendations for when to start therapy
(updated January 2008)

HIV treatment should be started in anyone before their CD4 counts fall below 350.

HIV treatment is recommended regardless of CD4 count for:

• anyone with a history of an AIDS-defining illness
• pregnant women
• people with HIV Associated Nephropathy (HIVAN)
• people co-infected with hepatitis B virus (HBV) for whom treating HBV is warranted

The risk of death or serious illness in people with CD4 counts above 350 is low. Any benefit from starting treatment at high CD4 counts is likely to be small.

However, some data — for example the ATHENA study — show that people who start therapy with CD4 counts above 350 will more likely maintain CD4 counts above 800. A Johns Hopkins study shows that people who started treatment with CD4s below 350 would less likely maintain CD4 counts above 500.

Starting HIV therapy earlier helps reduce the transmission of HIV.

Factors weighing against early treatment are:

• lifelong treatment;
• lack of long-term data on most HIV drugs;
• potential for developing drug resistance; and
• interference with quality of life.