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Considerations prior to initiating antiretroviral therapy

John G Bartlett, MD
Section Editor
Martin S Hirsch, MD
Deputy Editor
Jennifer Mitty, MD, MPH


At the time of the introduction of potent combination antiretroviral therapy (ART) in 1996, there was a "hit hard and hit early" approach to treatment [1]. However, when the toxicities and resistance of chronic ART became apparent and complicated dosing regimens thwarted adherence, the pendulum swung back to withholding therapy in patients with relatively preserved CD4 cell counts.

Advances in HIV therapy in the last decade have shifted the risk-benefit ratio to earlier treatment. The institution of effective ART can reduce HIV-related morbidity and mortality and decrease HIV transmission. HIV treatment guidelines from the United States Department of Health and Human Services (DHHS) and the International Antiviral Society-USA (IAS-USA) panels now recommend antiretroviral treatment in all patients with HIV infection, regardless of CD4 cell counts [2,3]. The strength of evidence supporting this recommendation varies by the pretreatment CD4 cell count.

This topic will address issues related to the evaluation of the chronically infected HIV-seropositive patient prior to starting therapy and other specific considerations that may influence treatment decisions in the individual patient. Indications for initiating ART in the chronically infected HIV-infected patient, relative efficacy of different regimens, patient evaluation, and laboratory monitoring are discussed elsewhere. (See "Patient monitoring during HIV antiretroviral therapy" and "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient" and "When to initiate antiretroviral therapy in HIV-infected patients".)

Issues related to the initiation of HIV therapy in the patient with acute HIV infection are discussed elsewhere. (See "Acute and early HIV infection: Treatment".)


A patient’s readiness to adhere to lifelong chronic therapy must be assessed prior to treatment initiation, although the urgency to start antiretroviral therapy (ART) is greater in patients with advanced immunocompromise. Certain patient considerations and comorbidities will also affect selection of specific antiretroviral medications.


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Literature review current through: Jan 2017. | This topic last updated: Fri May 22 00:00:00 GMT+00:00 2015.
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  1. Ho DD. Time to hit HIV, early and hard. N Engl J Med 1995; 333:450.
  2. Günthard HF, Aberg JA, Eron JJ, et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:410.
  3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf (Accessed on April 08, 2015).
  4. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487.
  5. Moss AR, Hahn JA, Perry S, et al. Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study. Clin Infect Dis 2004; 39:1190.
  6. de Pokomandy A, Rouleau D, Ghattas G, et al. HAART and progression to high-grade anal intraepithelial neoplasia in men who have sex with men and are infected with HIV. Clin Infect Dis 2011; 52:1174.
  7. Hessol NA, Holly EA, Efird JT, et al. Anal intraepithelial neoplasia in a multisite study of HIV-infected and high-risk HIV-uninfected women. AIDS 2009; 23:59.
  8. Palefsky J. Human papillomavirus-related disease in people with HIV. Curr Opin HIV AIDS 2009; 4:52.
  9. van der Snoek EM, van der Ende ME, den Hollander JC, et al. Use of highly active antiretroviral therapy is associated with lower prevalence of anal intraepithelial neoplastic lesions and lower prevalence of human papillomavirus in HIV-infected men who have sex with men. Sex Transm Dis 2012; 39:495.
  10. Davis HF, Skolasky RL Jr, Selnes OA, et al. Assessing HIV-associated dementia: modified HIV dementia scale versus the Grooved Pegboard. AIDS Read 2002; 12:29.
  11. Cysique LA, Maruff P, Brew BJ. Prevalence and pattern of neuropsychological impairment in human immunodeficiency virus-infected/acquired immunodeficiency syndrome (HIV/AIDS) patients across pre- and post-highly active antiretroviral therapy eras: a combined study of two cohorts. J Neurovirol 2004; 10:350.
  12. Sacktor N, McDermott MP, Marder K, et al. HIV-associated cognitive impairment before and after the advent of combination therapy. J Neurovirol 2002; 8:136.
  13. Lubinski C, Aberg J, Bardeguez AD, et al. HIV policy: the path forward--a joint position paper of the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians. Clin Infect Dis 2009; 48:1335.
  14. Chui CK, Brumme ZL, Brumme CJ, et al. A simple screening approach to reduce B*5701-associated abacavir hypersensitivity on the basis of sequence variation in HIV reverse transcriptase. Clin Infect Dis 2007; 44:1503.
  15. Moore JP, Kitchen SG, Pugach P, Zack JA. The CCR5 and CXCR4 coreceptors--central to understanding the transmission and pathogenesis of human immunodeficiency virus type 1 infection. AIDS Res Hum Retroviruses 2004; 20:111.
  16. Sonnenberg P, Glynn JR, Fielding K, et al. How soon after infection with HIV does the risk of tuberculosis start to increase? A retrospective cohort study in South African gold miners. J Infect Dis 2005; 191:150.
  17. Aichelburg MC, Rieger A, Breitenecker F, et al. Detection and prediction of active tuberculosis disease by a whole-blood interferon-gamma release assay in HIV-1-infected individuals. Clin Infect Dis 2009; 48:954.
  18. Hammer SM, Eron JJ Jr, Reiss P, et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel. JAMA 2008; 300:555.
  19. Chou R, Fu R, Huffman LH, Korthuis PT. Initial highly-active antiretroviral therapy with a protease inhibitor versus a non-nucleoside reverse transcriptase inhibitor: discrepancies between direct and indirect meta-analyses. Lancet 2006; 368:1503.
  20. Ziagen (abacavir) [package insert]. Research Triangle Park, NC: GlaxoSmithKline Inc.
  21. Soriano V, Puoti M, Garcia-Gascó P, et al. Antiretroviral drugs and liver injury. AIDS 2008; 22:1.
  22. D:A:D Study Group, Sabin CA, Worm SW, et al. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: a multi-cohort collaboration. Lancet 2008; 371:1417.
  23. Lundgren J, Neuhaus J, Babiker A, et al. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the SMART study. XVII International AIDS Conference, Mexico City, August 3-8, 2008. Abstract #THAB0305.
  24. Cutrell A, Hernandez J, Yeo J, et al. Is abacavir-containing combination antiretroviral therapy associated with myocardial infarction? No association identified in pooled summary of 54 clinical trials. XVII International AIDS Conference, Mexico City, August 3-8, 2008. Abstract # THAB0305.
  25. Ribaudo HJ, Benson CA, Zheng Y, et al. No risk of myocardial infarction associated with initial antiretroviral treatment containing abacavir: short and long-term results from ACTG A5001/ALLRT. Clin Infect Dis 2011; 52:929.
  26. Gallant JE, Winston JA, DeJesus E, et al. The 3-year renal safety of a tenofovir disoproxil fumarate vs. a thymidine analogue-containing regimen in antiretroviral-naive patients. AIDS 2008; 22:2155.
  27. Gallant JE, Moore RD. Renal function with use of a tenofovir-containing initial antiretroviral regimen. AIDS 2009; 23:1971.
  28. Cooper RD, Wiebe N, Smith N, et al. Systematic review and meta-analysis: renal safety of tenofovir disoproxil fumarate in HIV-infected patients. Clin Infect Dis 2010; 51:496.
  29. Sax PE, Tierney C, Collier AC, et al. Abacavir-lamivudine versus tenofovir-emtricitabine for initial HIV-1 therapy. N Engl J Med 2009; 361:2230.
  30. Sax PE, Tierney C, Collier AC, et al. Abacavir/lamivudine versus tenofovir DF/emtricitabine as part of combination regimens for initial treatment of HIV: final results. J Infect Dis 2011; 204:1191.
  31. Smith KY, Patel P, Fine D, et al. Randomized, double-blind, placebo-matched, multicenter trial of abacavir/lamivudine or tenofovir/emtricitabine with lopinavir/ritonavir for initial HIV treatment. AIDS 2009; 23:1547.
  32. Fiore AE, Shay DK, Broder K, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 2009; 58:1.