When should HIV medications be started?

Some data suggest earlier is better, but physicians say treatment initiation often has more to do with the patient than the science.

By Victoria Stagg Elliott, AMNews staff. Sept. 11, 2006.

The key question: Sooner or later?

It has to do with when to initiate antiretroviral therapy in patients with HIV.

And recently, debate over the answer is being fueled by a growing body of data indicating that starting earlier might produce fewer side effects and better outcomes.

"Is there a right time or a better time when these drugs should be given?" asked Michael Mugavero, MD, assistant professor of infectious diseases at the University of Alabama at Birmingham.

This issue has been a matter of dispute since it became possible to treat HIV. The most recent guidelines, which were developed by the International AIDS Society-USA and published in the Aug. 16 Journal of the American Medical Association, recommend that all patients experiencing symptoms start therapy.

For those who are asymptomatic, therapy should be initiated after the CD4 count dips below 350 but before it hits 200. Therapy can be started earlier if this number is declining rapidly or the viral load is high.

The recommendations are supported by solid evidence, although many physicians say they try to start closer to 350 than 200 or even at higher numbers if appropriate. And some wonder whether it is wise to wait at all.

"If you know somebody is infected, why would you allow the organism to expand in the person?" asked Ken Lichtenstein, MD, professor of infectious diseases at the University of Colorado Health Sciences Center in Denver. "Being infected is really an indication to treat."