When Should I Start Treatment & What Should I Take? : When should treatment be started?

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When Should I Start Treatment & What Should I Take?
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When should treatment be started?

Working closely with your health care provider, you can determine when the best time is to start treatment. Though HIV treatment, at least for people living with HIV in the United States, is recommended for all people living with HIV—essentially, it should be started soon after HIV is diagnosed—the decision to begin therapy depends on your physical health and your mental readiness to start treatment and stick with it.

In terms of physical health, your CD4 cell count, how you feel and your medical history all play 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 and certain HIV-related health problems can occur at even higher CD4 cell levels.  

Experts strongly recommend that HIV treatment be started once the CD4 count falls to 500 or lower. This recommendation is based on the results of clinical trials and cohort studies. As for those with CD4 counts above 500, experts also recommend therapy, though not strongly because neither clinical trials nor long-term cohort studies have confirmed whether the benefits of starting antiretroviral treatment earlier—essentially used by everyone living with HIV—outweigh the potential risks. 

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

Lesson Understanding Your T-cell Test

Antiretroviral treatment is also strongly 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:

Lesson 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 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 isn't commonly used to figure out when therapy should be started. 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:

Lesson 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 guidelines, last updated in May 2014, recommend:

Antiretroviral therapy is recommended for all people living with HIV to reduce the risk of AIDS- and non-AIDS-related illnesses. The strength of this receommendation depends on the HIV-positive person's pre-treatment CD4 cell count. For those with a pre-treatment CD4 cell count of 500 or below, the recommendation is strong (based on sufficient quality and quantity of research data). For those with a pre-treatment CD4 cell count above 500, the recommendation is optional (based on expert opinion).

Antiretroviral therapy is recommended for people living with HIV for the prevention of HIV transmission. This recommendation is based on research showing that when HIV treatment is used effectively by those living with the virus, it can effectively reduce the amount of virus in the blood (and genital fluids). As a result, those living with HIV are significantly less likely to transmit the virus to others. Data to support this recommendation are strongest from studies evaluating the effects of antiretroviral therapy on mother-to-child HIV transmission rates and among heterosexual couples in which one partner is HIV positive and the other is HIV negative. The recommendation for other risk groups, such as men who have sex with men, is also strong, but is based on less conclusive research.

Antitretroviral therapy is a committment that requires people living with HIV to understand the risks and benefits of therapy, as well as the importance of adhering to treatment (e.g., taking medications every day, exactly as prescribed). A person living with HIV who does not feel as if he or she is ready to commit to treatment or strictly adhere to his or her regimen may opt to postpone treatment. Similarly, health care providers who have concerns that a patient may not be adhere to treatment (e.g., because of mental health challenges, illicit drug use, other major medical problems, etc.) may also elect to defer treatment.

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Last Revised: April 20, 2015

This content is written by the POZ and AIDSmeds editorial team. For more information, please visit our "About Us" page.

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