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:
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:
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:
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:
| Health Status and CD4 Cell Count |
Recommendation |
- History of an AIDS-defining illness (see our list of opportunistic infections)
- CD4 count less than 350
- Pregnant women*
- A diagnosis of HIV-associated nephropathy (kidney disease caused by HIV infection)
- People coinfected with hepatitis B virus (HBV) and HIV, when HBV treatment is recommended. The treatment regimen selected should include antiretrovirals active against HIV and HBV (Viread and/or Emtriva or Epivir, for example).
|
Antiretroviral therapy should be started. |
- Patients with CD4 counts above 350 who do not meet any of the other specific conditions listed above
|
The best time to begin antiretroviral therapy in patients who do not have HIV-related symptoms and have CD4 counts above 350 has not been determined. However, each patient's health—including other infections or medical issues he or she has—should be taken into consideration when deciding whether or not to begin treatment early (see the next section of this lesson). |
| * For women who do not require antiretroviral therapy for their own health—their CD4 cell count remains above 350, for example—it is possible to discontinue treatment after the baby is born. |
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.
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