There is no clear evidence on when is the best time for you to start taking anti-HIV drugs. This means that you must weight up with your doctor, the likely benefits and risks for you of taking treatment now, as opposed to waiting until later. The current view is that treatment is clearly beneficial:

• If you have symptoms of HIV or AIDS.

• If you have a CD4 cell count around 350.  

If you have contracted HIV very recently

The six month period which follows immediately after you contracted HIV is called primary infection. There is no proof that starting treatment at this time will definitely lead you to live a longer, healthier life.

Some doctors believe, however, that this time may offer a unique chance to intervene which may be lost later in infection as your immune system sustains ongoing damage, and so may be less able to respond to HIV itself.

However most people do not find out that they have been infected until they develop symptoms many months or years later.

This potential benefit has to be weighed against the risk of you getting side-effects of the drugs finding that treatment reduces your quality of life, and the possibility that if the treatment you take stops working effectively against HIV, you may be left with drug resistant virus.

The results of small studies looking at the risks and benefits of treatment soon after infection with HIV are far from conclusive. Some people who took anti-HIV treatment very soon after infection seem to have maintained extremely low levels of HIV, even after stopping treatment. But on the other hand, others who have tried the same strategy have not had this response. Because there is a lack of clarity, a much larger clinical trial is currently looking at the benefits of treatment at this stage. Its results will be available in a few years.

Until these results are available, the only people who are recommended to consider treatment soon after they’ve been infected with HIV are those with:

• Any AIDS-defining illness.
• Neurological (brain) conditions that are related to HIV.
• A CD4 cell count that is below 200 for three months or more.

If you have established (chronic) infection but not had HIV symptoms

You should certainly start anti-HIV treatment before your CD4 count falls below 200. 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.

There is now a consensus that there are benefits to starting anti-HIV treatment when your CD4 cell count is around 350. Your doctor should discuss starting anti-HIV treatment when your CD4 cell count is around this figure and you are recommended to start treatment as soon as you are ready. There is good evidence that starting treatment when your CD4 cell count is in the region of 350 reduces your risk of developing not only HIV-related illnesses but also other serious illnesses as well, including heart, kidney and liver disease and some cancers.

Treatment with a CD4 cell count of 350 is particularly encouraged for people who have any of the following characteristics:

• A viral load above 100,000.
• A rapidly falling CD4 cell count (80 cells or more a year).
• Any HIV-related illnesses.
• Coinfection with hepatitis B virus or hepatitis C virus.
• Age over 50 years.
• A risk of heart disease.
• In a relationship with somebody who is HIV-negative.
• Some doctors also believe that starting treatment at this time advisable for people of African origin who have 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.

People with symptoms of HIV disease or AIDS

Everybody who has been diagnosed with an AIDS-defining infection or cancer is recommended to start anti-HIV treatment. An exception is tuberculosis (TB) if your CD4 cell count is above 350 (see the booklet in this series, HIV and TB for more details).

In most cases, anti-HIV treatment will be started once you’ve finished treatment for your infection. This is because anti-HIV drugs can sometimes interact with medicines used to treat infections. There can also be a risk of a set of unpleasant symptoms called an immune reconstitution inflammatory syndrome if you take treatment for some infections and anti-HIV therapy close together.  

If you have been diagnosed with lymphoma, you should start anti-HIV treatment as soon as you commence chemotherapy.