HIV | Start of treatment

An effective treatment reduces the number of newly produced HIV particles, so that fewer cells are infected and the deterioration of the immune system is stopped and reversed.

In general, it is never too late for antiretroviral therapy, but the later the treatment is started the more the immune system is already impaired. In this situation the treatment may become more problematic with regard to response rates and side effects. In addition during a transition period there is an increased risk of opportunistic infections until the resolution of the immune deficiency. The decision on when to start treatment should be discussed in detail with your treating physician, considering all aspects (i.e. physical condition, laboratory results, other medical conditions, social context).

Starting antiretroviral therapy

The current recommendation is to offer antiretroviral therapy to every HIV infected patient regardless of helper cell count and viral load. Apart from preventing HIV associated diseases inhibiting transmission of HIV by effective antiretroviral therapy is an important reason. However, personal preferences when to start can be taken into account as long as there is no urgent need due to advanced immune deficiency.

Indications for an immediate start of antiretroviral therapy are:

  • symptoms associated with HIV infection such as fever, night sweats, loss of weight, persistent swelling of lymph nodes and other symptoms
  • permanent reduction of the absolute helper cell count to less than 350 cells per microliter or sustained reduction of relative helper cells below 15 %

If the absolute helper cell count is less than 200/µl or if the relative count declines to less than 15 % the risk of life-threatening opportunistic diseases is high.

In this situation, it is essential to begin antiretroviral therapy to improve the immune system and to prevent opportunistic infections. Specific prophylaxis of opportunistic infections should be initiated and continued until the resolution of the severe immune deficiency.

Antiretroviral therapy is generally considered life-long. Planned interruptions are possible in specific situations. Curing HIV is not possible to date, but long term antiretroviral therapy offers the perspective of a near normal life expectancy despite HIV infection.

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Resistance testing

Before starting antiretroviral treatment it is sensible to perform HIV resistance testing. Transmission of drug resistant HIV is well documented. Information about the presence of drug resistant HIV at the time of the start of antiretroviral therapy will help clearly guide the choices concerning the individual antiretroviral combination therapy.

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