Understanding the Details of HIV Treatment

When to Start: Some General Issues

Some people will start HIV treatment right away, while others may wait for awhile. The following factors can help you and your provider choose the best time to start.

Your CD4 Count Trend

A trend is when you look at two or more CD4 count results to see how much they change. Over time, falling CD4s indicate declining immune health. There's general agreement that a loss of 100 CD4s or more each year shows a weakening immune system. Don't panic about a single lower test result, but consult with your doctor and consider another test to determine your trend.

The CD4 percentage trend is also useful to consider. This tends to change less often between tests than the CD4 count, so it may be more reliable.

Your Viral Load Trend

Consistently increasing HIV levels indicate that the virus is reproducing and can infect more CD4s, which causes more damage to the immune system. Again, the trend over time is impor­tant: consider two or more viral load test results to inform a treatment decision. Experts generally agree that an increase in viral load to above 100,000 is a sign to start treatment, independent of CD4 count.

Your General Health

Your general health and whether or not you have minor symptoms can also help determine when to start. If your health is good and stable, then starting treatment right away may not be necessary. But if you have some symptoms of HIV disease, despite a good CD4 count, starting might be the better decision. On the other hand, if you have an illness that makes it difficult to adhere to or manage the side effects from the HIV drugs, it may be better to wait until you're feeling better and the other illness has resolved. Your doctor can help you make this decision.

Are You Ready to Start?

You should begin treatment when you feel you're ready for the demands of life-long treatment. This includes being emotionally ready, as well as being able to take pills every day, manage possible side effects, and ensure you have steady access to health care. It may mean you first need to address other issues such as finding stable housing or mental health or substance use services. Without a strong commitment to and support for taking your pills as prescribed, you're less likely to get the best outcomes.

HIV Treatment Guidelines

The US Department of Health and Human Services Guidelines for treating HIV infection are updated periodically, the last time in January 2011. They're meant to help guide people with HIV and their doctors through the issues that may arise when choosing and using HIV meds, including when to start and what drugs to use. The Guidelines are based on the latest research as interpreted by a panel of experts, which result in recommendations, not 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.

The Guidelines state that HIV treatment should be based on a person's own unique situation, best done with the expert advice of an experienced doctor. Important details from the Guidelines about when to start and what meds to choose are found over the next several pages.

The following conditions increase the need to start.

• CD4 count below 200
• an AIDS-defining illness
• loss of more than 100 CD4s each year
• viral load above 100,000
• certain OIs, such as cryptosporidiosis
• pregnancy
• people with HIV kidney disease, called HIVAN
• hepatitis B virus co-infection that requires treatment