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When to initiate antiretroviral therapy in HIV-infected patients

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 T cell counts.

Advances in HIV therapy in the last decade have shifted the risk-benefit ratio to earlier treatment. The 2012 United States Department of Health and Human Services (DHHS) Guidelines for HIV treatment now recommend antiretroviral treatment in all patients with HIV infection, regardless of CD4 cell counts [2]. This topic will discuss the strength of the evidence supporting these treatment guidelines.

The selection of specific medications, patient evaluation, counseling regarding side effects, and laboratory monitoring are discussed elsewhere. (See "Counseling HIV-infected patients regarding potential side effects of antiretroviral therapy" and "Patient monitoring during HIV antiretroviral therapy" and "Selecting antiretroviral regimens for the treatment naive HIV-infected patient" and "Considerations prior to initiating antiretroviral therapy".)

GOALS OF THERAPY

The primary goals of combination antiretroviral therapy are to increase disease-free survival through suppression of HIV replication and improvement in immunologic function [2,3]. Viral suppression also decreases the risk of HIV transmission to an uninfected sexual partner.

INDICATORS OF IMMUNE FUNCTION

The CD4 cell count is the main indicator of immune function in patients who are HIV-infected and is the strongest predictor of disease progression and survival [2,4,5]. It is also one of the key factors in deciding whether to initiate chemoprophylaxis for opportunistic infections and to evaluate clinical complications. (See "Primary prevention of opportunistic infections in HIV-infected patients".)

                                         

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Literature review current through: Apr 2012. | This topic last updated: May 4, 2012.
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