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Considerations prior to initiating antiretroviral therapy

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

INTRODUCTION

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" and "Overview of antiretroviral agents used to treat HIV".)

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".)

PATIENT EVALUATION PRIOR TO INITIATION OF ANTIRETROVIRAL THERAPY

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: Nov 2016. | This topic last updated: Fri May 22 00:00:00 GMT 2015.
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