When to start treatment

It’s not known for certain what is the best time to start treatment with anti-HIV drugs. This means you need to weigh up with your doctor, on an individual basis, the likely benefits and risks of starting treatment now as opposed to waiting until later.

However, it’s currently recommended in UK HIV treatment guidelines that you start taking HIV treatment immediately if you are ill because of HIV, or have an AIDS-defining illness. If you do not have any symptoms, then UK treatment guidelines (published in 2008) recommend that you start treatment when your CD4 cell count is around 350.  Your doctor should start discussing HIV treatment with you when your CD4 cell count is around this figure and you are advised to start treatment as soon as you are ready.

UK treatment guidelines also make other recommendations about whether you should take HIV treatments, depending on the length of time you have been infected with HIV, the level of your CD4 cell count and the amount of HIV in your blood – your viral load.

The six-month period after you are infected by HIV is called primary HIV infection. There is no proof that taking treatment at this time will mean that you live a longer, healthier life. Some doctors believe, however, that treatment at this time may offer a unique chance to control HIV that may be lost later, as your immune system sustains ongoing damage due to HIV and becomes less able to attack HIV. Whatever your CD4 cell count, if you are considering treatment during the period soon after infection, you should start as soon as possible, and certainly within six months of infection with HIV. Clinical trials are underway to assess the effectiveness of taking HIV treatment at this stage and you might wish to consider joining one.

The potential benefits of taking treatment at this time need to be weighed up against the possibility of side-effects. Treatments may reduce your quality of life at a time when HIV would not have. There is also a possibility that if your treatments don’t work effectively against HIV, drug resistance could develop, and you would have fewer drug options if you become ill because of HIV.

A very small number of people become really quite ill during primary infection with HIV, and it is recommended that you take HIV treatment at this stage if:

• You have an AIDS-defining illness.
• You have a brain condition that is connected with HIV.
• You have a CD4 cell count that is below 200 (the level associated with a real risk of becoming very ill because of HIV) for three months or more.

However, most people do not find out that they have HIV until months or years after infection.

Ideally, you should begin treatment before your CD4 count falls below 200. This is because if you start treatment when your CD4 count is below 200, you face a greater risk of ill health and even death, in the short term, than if you start while your CD4 count is still above 200.

But doctors believe that the long-term effectiveness of HIV treatment is improved if a person starts taking it when their CD4 cell count is around 350. HIV treatment guidelines (published in 2008) recommend that HIV treatment should be started when your CD4 cell count is around 350.  Starting treatment at this time will reduce your risk of becoming ill because of HIV as well as some other serious illness as well.

It is a good idea to talk to your doctor about your CD4 count and when you should start treatment.  You may also wish to consider starting treatment earlier if you are also infected with hepatitis C virus, as liver disease becomes worse when the CD4 cell count is lower. There's a lot more information on hepatitis C in the section Non-HIV-related illnesses - hepatitis . It's also a good idea to start earlier treatment if you have a risk of heart or kidney disease.

If you are advised to start treatment but choose not to, then you should review your decision regularly and have your CD4 count and viral load monitored more frequently than usually recommended, say every two months.

Regardless of your CD4 cell count, doctors recommend that you should take HIV treatment if you are becoming ill because of HIV.

A possible exception, however, would be if you have tuberculosis. There are potential interactions between anti-HIV drugs and a key medicine used to treat tuberculosis. Because of this, many doctors recommend delaying treatment with anti-HIV drugs until a person has taken at least two months of tuberculosis treatment. Similarly, if you become ill with tuberculosis whilst taking HIV treatment, you may be recommended to stop taking anti-HIV drugs for the first two months of tuberculosis treatment.

If your CD4 cell count is below 200 you should start HIV treatment immediately. This is because you have a risk of developing potentially life-threatening illnesses when your CD4 cell count is this low. You may also need to take small doses of some antibiotics to prevent you developing some infections until your CD4 cell count increases to over 200 to 250.  But ideally you should start HIV treatment when your CD4 cell count is around 350 - this reduces your risk of becoming ill due to HIV and also means it is less likely you will develop some other serious illnesses as well.