When to start treatment

The earliest possible treatment is recommended for illnesses. Biologically, there is little reason to think that HIV is any different. In fact, early treatment may be even more important because of the seriousness of the disease. But just what "early" means in the case of HIV disease is not so clear.

Starting points for antiviral medications are the subject of a great deal of debate and theory. Some people believe that antiviral medication is appropriate immediately upon learning of the infection, whether or not the CD4+ count is falling, viral load is high or rising, or whether symptoms are evident. Waiting might only let the infection progress and spreads to other parts of the body.

At the most optimistic extreme, some researchers are testing whether beginning treatment almost immediately after infection might someday literally "eradicate" HIV infection. While this is an exciting hope, no one has yet successfully "eradicated" HIV. To be fair, no recently infected patient has undergone treatment for the time necessary for this to happen. If the hope of "eradication" is someday proven true, then all the debates about when to start treatment will end. In the meantime, eradication is a concept, not a proven reality. Those who believe eradication is possible argue for the earliest possible treatment.

A second argument in favor of early treatment is that this may prevent the loss of critical cells in the immune system. But since we don't know exactly when the loss of such cells occurs, it is still hard to know "when" is the right time to start.

Some researchers prefer to withhold treatment until later in the course of disease. They believe it is best to save the drugs for later when the virus is more active or when the immune system shows obvious damage. They fear that treating too early it may "use up" the medicines before they are most critically needed, or that people will experience long-term toxicity from the drugs. Since none of the current medications can be used indefinitely, this argument cannot be casually dismissed. Even these researchers, however, believe it wise to start before there is evidence of major damage to the immune system. Just "when" that occurs is unclear.

The only way we will get clear answers to these questions is when more clinical trials are completed. In the meantime, the question remains a matter of personal choice. For information about starting treatments based on viral load test results, read the Project Inform document on viral load.

Almost all researchers agree that it is necessary to start antivirals when symptoms are present, when the CD4+ count is falling, or the viral load is high.

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