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 fact, immune system damage can occur at even higher CD4 cell levels. In turn, experts suggest that HIV treatment be started well before the CD4 count drops below 200; it is generally recommended that antiretroviral therapy be started once the CD4 count falls below 500. Some experts even recommend starting treatment when the CD4 count is above 500; basically, as soon as possible after HIV diagnosed.
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 guidelines, revised in October 2011, 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), regardless of the CD4 cell count.
- People coinfected with hepatitis B virus (HBV) and HIV, regardless of the CD4 cell count, 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 between 350 and 500
|
Antiretroviral therapy is recommended. |
- Patients with more than 500 CD4 cells.
|
No clear recommendation (half of guidelines panelists recommend starting therapy as soon as possible). |
| * For women who do not require antiretroviral therapy for their own health—based on the current guidelines —it is possible to discontinue treatment after the baby is born. |
The panel of experts that make up the DHHS guidelines committee unanimously recommended that people should initiate ARV treatment when their CD4 count is between 350 and 500. However, the panel was divided on the strength of this recommendation: 55 percent of panel members voted for strong recommendation and 45 percent voted for moderate recommendation.
The panel of experts was evenly split on whether to recommend ARV treatment for people with CD4 counts greater than 500—essentially everyone diagnosed with HIV infection, regardless of their CD4 count. Fifty percent of the panel members favored starting antiretroviral therapy; the other 50 percent of members viewed treatment is optional in this setting.
Importantly, the guidelines panel stresses that the decision to start ARV therapy should not be based solely on a person's CD4 cell count. It is important for people living with HIV to first be able to commit to life-long HIV treatment, and be fully aware of both the importance of adherence and the risks and benefits of treatment. Treatment can be delayed, for example, if an HIV-positive person is dealing with issues that might limit the success of therapy, including acute medical problems, psychological issues (i.e., depression), or social issues (i.e., lack of housing). In other words, people with HIV and their health care providers will have to weigh their options carefully when considering earlier HIV treatment.
Though the guidelines panel indicate that deferring ARV therapy may be appropriate in some cases, the panelists also highlight several conditions that increase the urgency for treatment. These are:
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