AEGiS-ATDN: Jump Start My HAART: When to start HIV treatment?

Important note: Information in this article was accurate in 2002. The state of the art may have changed since the publication date.

Jump Start My HAART: When to start HIV treatment?

Information Bulletin #16 - August 2002

Until recently, the generally accepted way to treat HIV was aggressively, as soon as the HIV was diagnosed. This approach to treating HIV was called "Hit Early, Hit Hard", and it was based on the belief that you could get rid of HIV from the body with two or three years of intense therapy. Unless treatment is started within days of becoming infected, however, no one still believes that HIV can be eradicated with years of aggressive anti-HIV treatment. In fact, no one is really certain when the best time to start HIV treatment is, although the side effects that can develop once treatment is started have compelled researchers to look at ways to use powerful anti-HIV drugs when they are needed most.

When is the best time to start on HAART (Highly Active Anti-Retroviral Therapy)? As we find out more about how HIV works and the immune system's ability to fight it, official government treatment recommendations have changed along with our understanding of the disease. CD4 counts have emerged to be a more reliable signpost, compared to viral load. As more long-term drug side-effects began to emerge, and combination therapies continue to improve in terms of efficacy, the reasons to hold off on starting therapy as long as possible are convincing. Current treatment guideline says that people with CD4 counts at or below 350 should consider starting treatment.

Two new studies presented at the Conference this year suggest that there is possibly even more lead way before starting treatment. Researchers looked at two groups of people. One group started treatment when they had between 350 and 500 CD4 cells. The other group started when they had between 200 and 350 CD4 cells. What they found was that there were almost no difference between the two groups in terms of treatment success. Previous studies have clearly shown that people who start treatment when their CD4 fall below 200 have a much harder time regaining their health, as well as a higher risk of disease and death. These and other previous studies make a stronger case for waiting to start treatment when CD4 falls just above 200.

On the side of caution, however, there was a small study that argues against delaying therapy. The researchers compared people who started therapy when they had below 250 CD4 to people who started when they had above 250 CD4. The results showed that people who started later had a weaker immune response when they were vaccinated with various vaccines, suggesting that early treatment may either help the immune system bounce back to a stronger state, or prevent it from becoming weaker. A larger and longer study is needed to demonstrate this idea.

It can be scary to live with HIV in your blood and not treat it right away. It might not be worth all the worrying and second-guessing, and easier just to jump right into treatment. Many people have done so and benefited from doing so. Not everyone has severe side effects from medications. These are decisions that you and your doctor should carefully discuss. It is important to have your CD4 and viral load checked on a regular basis and be on the lookout for unusual or new symptoms that might develop if you decide to hold off on HAART.

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