When Should I Start Treatment, and What Should I Take First? en español

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Introduction

Deciding when to start HIV treatment—and figuring out which drugs to start with—is, perhaps, one of the most difficult decisions you will need to make. And, depending on which way you look at it, the fact that everyone has different opinions regarding these issues can be either helpful, frustrating, or a combination of both.

Learning all you can about the pros and cons of your various treatment options is your best weapon in the fight against HIV. The following questions & answers (Q&A) are intended to provide you with the necessary information you need to communicate effectively with your doctor as you discuss these options.

Why is treatment necessary?

If HIV is allowed to reproduce, or "replicate," inside the body, it will cause damage to the immune system. Ultimately, the immune system gets so weak that the body becomes vulnerable to other diseases. This is the point at which a person is usually diagnosed with full-blown AIDS, and the other diseases they get can eventually cause death. For adults who live in wealthy nations—such as the United States—the average time between becoming infected with HIV and the development of AIDS is 10 years.

This does not, however, include people who take HIV drugs. Clinical trials—studies in which new and old drugs are tested in humans—have repeatedly shown that HIV drugs can keep HIV-infected people alive longer. Treatment, therefore, is a very important option, and people living with the virus should consider starting treatment before HIV has had a chance to do serious damage to their immune systems.

When will I know that it's time to start treatment?

There's really no right or wrong answer—it all depends on the individual. Working closely with your doctor, you can determine when the best time is to start treatment. This will largely depend on two factors: your physical health and your mental readiness to start therapy and stick with it.

In terms of physical health, your CD4 cell count, how you feel and your medical history all play major roles when figuring out when to start HIV treatment.

CD4 cells—also known as T-cells, T-helper cells, or T4-cells—belong to a group of white blood cells called lymphocytes. These cells have the double distinction of not only being the primary target of HIV, but also carry the responsibility of coordinating the way in which the immune system responds to disease-causing infections. When the CD4 cell count—the number of cells in a cubic millimeter or milliliter of blood—drops below 200, the immune system is considered to be "compromised" and you are at a higher risk of experiencing an AIDS-related opportunistic infection, like Pneumocystis pneumonia. In turn, experts suggest that HIV treatment be started before the CD4 count drops below 200; it is generally recommended that antiretroviral therapy be started once the CD4 count falls below 350.

For more information about CD4 cells and the test to measure them, click on the following lesson link:

Understanding Your T-cell Test

Antiretroviral treatment is also recommended for HIV-positive people with specific medical situations, regardless of the CD4 cell count. For example, it is recommended that HIV-positive women use treatment if they become pregnant, in order to reduce the risk of transmitting the virus to their babies. Antiretroviral therapy is also recommended for people experiencing HIV-associated nephropathy (HIVAN), a form of kidney disease that can occur at any CD4 cell count. There are also people infected with both HIV and hepatitis B virus (HBV). Because some of the drugs used to treat HIV—such as Truvada (tenofovir/emtricitabine), Viread (tenofovir), Emtriva (emtricitabine) and Epivir (lamivudine)—can also be used to treat HBV infection, starting an HIV drug regimen that contains these medications is recommended for coinfected patients who require HBV treatment (regardless of the CD4 cell count).

For more information about these other medical conditions, click on the following lesson links:

Family Planning, Pregnancy & HIV Risks to Your Kidneys: A Complete Guide to Renal Health Hepatitis B

In the past, viral load—the amount of HIV in a milliliter of blood—was much more widely used to help patients and their health care providers decide when to begin treatment. The higher the viral load, experts suggested, the faster someone might see his or her CD4 cell counts fall to dangerously low levels. Even if a patient had a relatively healthy CD4 count, treatment might still be recommended if he or she had a high viral load. Today, viral load is less frequently used to figure out when therapy should be started, given that the CD4 cell count alone is considered to be highly reliable. But viral load testing is still a routine component of HIV treatment, notably to help patients and their doctors determine if treatment is working correctly (see "Once I've started treatment, how will I know it's working for me?" below to learn more). For more on viral load testing, click the following lesson link:

Understanding Your Viral Load Test

The U.S. Department of Health and Human Services (DHHS)—the federal agency responsible for setting health-related policies in the United States—regularly updates and publishes HIV treatment guidelines to help HIV-positive patients and their health care providers determine when antiretroviral therapy should be started. Here is what the latest guidelines, published in January 2008, recommend:

The big question is—and this is quite a point of controversy—should you consider starting therapy early? "Early" is now generally defined as a CD4 cell count above 350. Some experts believe that therapy should be started early, before the T-cell count shows signs of immune-system damage. Others argue that starting therapy early isn't any better than starting therapy later, and that you should wait to start therapy until your CD4 cells have fallen below 350.

So which is it? Is it better to start therapy early or wait until my CD4 cell count drops?

We now know that HIV cannot be cured, or "eradicated," using the anti-HIV drugs that are currently available. However, we do know that therapy should be started—and continued—before HIV has had a chance to cause serious damage to the immune system. In this sense, it is always best to start therapy before symptoms of AIDS occur.

There is still some debate though on just how early treatment should start. More specifically, it is not clear if antiretroviral therapy should be started before the CD4 count falls below 350. While there are some potential benefits of early treatment, there are also possible risks. Here is a list of both, to help you and your healthcare provider determine if early treatment may be right for you:

Potential Benefits

• Keep your CD4 count high and possibly prevent irreversible damage to the immune system.
• Decrease your risk of certain HIV-related health problems that can sometimes occur in people with CD4 counts above 350, including tuberculosis, non-Hodgkin's lymphoma, Kaposi's sarcoma, peripheral neuropathy, cancers and pre-cancers caused by human papillomavirus (HPV), and mental deficits seen in some people with HIV such as difficulty thinking and reasoning (neurocognitive problems).
• Decrease your risk of serious health problems that occur more frequently in HIV-positive people, such as cardiovascular disease, kidney disease, liver disease, and various non-AIDS-related cancers and infections.
• Reduce your risk of transmitting HIV to others.

Potential Risks

• Risk developing treatment-related side effects.
• Risk developing HIV drug resistance, resulting in loss of future treatment options.
• Less time for you to learn about HIV and its treatment, and less time to prepare for adherence to therapy.
• Premature use of treatment before the development of more effective, less toxic, and/or better studied combinations of HIV drugs.
• Increased risk of transmitting drug-resistant HIV to others if you have a detectable viral load while on treatment.

Okay, I'm ready to start therapy. What should I take?

The U.S. Department of Health and Human Services (DHHS) guidelines are quite strict about which drugs HIV-infected people should start with. If the point of therapy is to decrease viral load to the lowest possible level—"undetectable" as determined by viral load testing—for as long as possible, the most effective drugs must be used to achieve this. Simply put, the most effective anti-HIV drugs should be used in combination with each other to ensure that maximum pressure is being placed on the virus.

An anti-HIV drug regimen should consist of at least three drugs, usually from at least two classes of anti-HIV drugs. For an explanation of how each class of anti-HIV drugs stops the virus from replicating, click on the following lesson link:

The HIV Life Cycle (and the targets of each class of anti-HIV drugs)

The following table is based on the most recent version of the DHHS guidelines, last updated in January 2008.

While the DHHS guidelines seem very specific and overwhelming, the experts responsible for making these recommendations stress a very important point: that selecting a drug regimen should be based on an HIV-positive person's individual needs. In other words, an HIV-positive person may have specific needs with respect to a drug combination's effectiveness (perhaps against drug-resistant virus), side effects (some people may be more sensitive to certain adverse effects than others), drug interactions (some HIV drugs are difficult to combine with other medications HIV-positive people take), and other infections or illnesses (people with hepatitis B or hepatitis C may need to be treated with certain HIV drugs very carefully).

The DHHS also recommends the use of drug-resistance testing to help figure out which anti-HIV drugs should be used as first-time treatment. This is because some people are infected with drug-resistant strains of HIV that may limit certain anti-HIV drug treatment options, even in people starting treatment for the first time. To learn more about HIV drug resistance and drug-resistance testing, click here:

Understanding Drug Resistance & The Tests to Measure It

Above all, it is important that you take the correct dose of your medications every time you're supposed to take them, exactly as prescribed by your health care provider or recommended by your pharamcist. This is called treatment adherence—you need to take your medications correctly if they are to keep you healthy. To learn more about treatment adherence, click here:

The Importance of Adhering to Your Treatment Regimen

What about for pregnant women? Isn't treatment risky to the developing baby?

Women, whether or not they are pregnant, should be treated using HIV drugs in accordance with their own health needs. In other words, women should not be forced to compromise their own health simply because they are pregnant. Many HIV therapies do, in fact, have a positive impact on the life and health of the baby. For detailed information about pregnancy and HIV, including a review of the best medications to use, click on the following lesson link:

Family Planning, Pregnancy & HIV

Once I've started treatment, how will I know it's working for me?

When HIV drug therapy is started—preferably with a powerful combination of drugs—the level of HIV should start to drop dramatically. This is where viral load testing comes in. During the first two months of therapy, an HIV-infected person's viral load should drop a minimum of 90%. In other words, someone who starts treatment with a viral load count of 100,000 should drop to 10,000 or less within two months. Within 4 to 6 months of starting therapy, the viral load should have dropped a lot more, hopefully below the level of the viral load test's sensitivity ("undetectable"). Sometimes undetectable means a count less than 400 or 500, but newer tests can detect as few as 50. Generally, the higher your viral load is before starting therapy, the longer it will take to become undetectable.

As for your CD4 cell count, you will likely see an increase between 100 and 200 cells in the first 12 to 18 months, and can gradually climb from there as long as viral load remains undetectable.

It's working! What's next?

You and your doctor should continue monitoring your viral load on a regular basis to make sure that the HIV drugs are working properly and that the amount of virus in the blood remains below the level of detection or as low as possible.

If your viral load increases while taking HIV drugs, this may mean that drug resistance has occurred. To learn more about resistance and the treatment options that are available if it occurs, click on the following lesson links:

Understanding Drug Resistance & The Tests to Measure It When Should I Change My Treatments, and Which Drugs Should I Switch To?

It is important to be careful when watching changes in viral load. This is because the tests are very sensitive and may produce slightly different results. A change must be greater that 3-fold to be real. In other words, an increase from 10,000 to 25,000 may only be due to the sensitivity of the test and not necessarily a true change in viral load.

You should also have your CD4 cell count checked regularly—usually every 3 to 6 months.

And be sure to discuss with your doctor any problems you are having with your treatment regimen without delay. If you find yourself missing doses or experiencing side effects, you might be able to switch your current regimen for one that is easier to take or associated with fewer side effects. But it is crucial that you do this sooner rather than later.

This content is written by the editorial team at AIDSmeds.com.
Please find profiles of this team on our "About Us" page.