Antiretroviral Therapy: When to Start, What to Start With

Recent guidelines on initiation of antiretroviral therapy (ART) have been modified because HIV is no longer likely to be eradicated by treatment; toxicity with ART is increasingly recognised and adherence wanes with time. Even late treatment (CD4 count less than 200 cells/µl) is associated with sufficient immune reconstitution in most patients to avoid opportunistic infections. The optimum starting treatment is unknown. Relatively similar results in terms of viral load reduction at 48 weeks are produced by a wide variety of triple therapy regimes. Factors that can be used to decide optimal first treatment in the absence of controlled studies include potency, durability, salvageability, freedom from side effects, ease of long term adherence and the degree of flexibility around the timing of individual doses (forgiveness).