Starting Drug Treatment: When

Last, but definitely not least, we come to the use of antiretroviral therapy. Although even the best HAART combinations cannot cure HIV infection, they can usually help to control the virus, promote significant immune restoration, and slow or even reverse disease progression. When successful treatment combinations can be found, the immune decline that might otherwise continue is often stopped and usually restored to levels that are sufficient to prevent opportunistic infections and otherwise restore good health. However, growing concerns about the long-term toxicity of the drugs and the difficulty of continuing over the long haul to take them perfectly as directed -- the absolute requirement for preventing resistance -- has made decisions about which therapy to use -- and when to begin it, change it, interrupt it, or stop it -- ever more difficult.

Deciding when to start drug treatment can be one of the most difficult choices to make. There are no hard-and-fast rules about beginning HAART. When triple-drug cocktails first became widely available in 1996, many experts recommended starting treatment as soon as possible. Their slogan was "hit early, hit hard." The idea was to use these powerful drugs to protect and preserve the immune system as much as possible. Since that time, expert opinion on starting HIV treatment has been modified to reflect new information about long-term side effects and drug resistance. We might call the new viewpoint "hit later, hit carefully."

In an attempt to provide guidance, groups of experts from around the world meet regularly and make recommendations for using HIV treatment. These guidelines change as research gives us new insight into HIV. The treatment guidelines are long, complex documents and different expert groups have slightly different opinions. However, their recommendations can be summarized for people considering starting treatment at the various stages of HIV infection:

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• During primary (acute) infection.

The idea behind starting treatment at this stage is to protect and preserve the highest level of immune function, and perhaps create a lifelong tendency toward a lower viral load due to the body's improved ability to control the virus. The benefits to starting treatment at this stage are mostly theoretical as there have been only a very few studies of people who have started this early in their infection. However, there is some evidence from the research done so far that this very early use of antiretrovirals for a period of time (and it does not have to be lifelong, although the exact length of the treatment period varies depending on the researcher you listen to) may, indeed, help preserve immune function. It will take considerably more research to know the long-term effectiveness and safety of such approaches.

• During asymptomatic infection when the CD4+ count is between 200 and 500.

Some doctors and PHAs prefer to delay treatment at this stage, while others will begin it. The precise point at which physicians will usually urge that treatment be started will vary from doctor to doctor, but it is most often based on their assessment of some combination of:

• CD4+ counts

• viral loads

• whether or not you have symptoms of HIV-related problems

• your readiness and ability to handle HAART

Doctors who generally delay starting treatment usually do more frequent testing of viral load and CD4+ counts to watch for new trends. When thinking about treatment at this stage, changes in the CD4+ count are probably more important than viral load (see "Interpreting Immune Cell Changes" section). Most experts would recommend that treatment be delayed if your CD4+ count is greater than 350 cells, particularly if your viral load is fewer than 55,000 copies and you are feeling fine. Some experts suggest treatment for people whose CD4+ counts are between 200 and 350 cells, depending on several factors as outlined in bullets above. You are an important factor in the decision about when to start treatment. Discuss your feelings and situation with your doctor.

• During symptomatic infection or when the CD4+ count drops below 200.

People who have had an AIDS-defining illness or who have symptoms of long-term infection will still benefit from starting HAART. Even if the immune system has been severely damaged, it can usually rebuild itself substantially.

If you have Internet access, you can review the most recent HIV/AIDS treatment guidelines at these websites:

• British Columbia Centre for Excellence in HIV/AIDS -- Therapeutic Guidelines for HIV/AIDS and Related Conditions:
  www.cfenet.ubc.ca/

• the British HIV Association:
  www.bhiva.org/

• the International AIDS Society-USA:
  www.iasusa.org/pub/index.html

• the U.S. Department of Health and Human Services:
  www.aidsinfo.nih.gov