Last revised, May 2008

Next due for revision, May 2009

Doctors are learning more about the best way to treat HIV, but it is still not known for certain when is the best time to start taking anti-HIV treatment.

There is no cure for HIV, but many doctors think that anti-HIV treatment could mean that a person with HIV has the chance to live a more or less normal lifespan.

Anti-HIV drugs work by lowering the amount of HIV in the blood (viral load). The aim of anti-HIV treatment is an undetectable viral load. Reducing the amount of HIV in your blood allows your immune system (measured by your CD4 cell count) to strengthen. The higher your CD4 cell count, the lower your risk of becoming ill because of HIV (and possibly some other serious illnesses as well).

You should discuss with your doctor the best time for you to start anti-HIV treatment. There are a number of factors you might want to consider, including:

• The benefits or starting treatment now.
• The potential risks if you delay starting treatment.
• Are you psychologically ready to start treatment now?
• Are there other factors in your life that affect your ability to start taking anti-HIV treatment?

When to start

It is recommended that you should start anti-HIV treatment if you are ill because of HIV. In most cases it is recommended that you complete treatment for any infection that you have developed before you start anti-HIV treatment.

If your CD4 cell count is 350 or below you are recommended to discuss anti-HIV treatment with your doctor, and start treatment as soon as you are ready.

People who have hepatitis B virus or hepatitis C virus, those aged over 50, and people with a high risk of heart disease are particularly recommended to start treatment when their CD4 cell count is around 350.

What to start with

Standard anti-HIV treatment for people starting HIV treatment for the first time is a combination of three different drugs. Anti-HIV drugs belong to different classes depending on the way they work against HIV. The three main classes of anti-HIV drug are nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and ritonavir-boosted protease inhibitors.

The preferred combination of anti-HIV drugs for people taking anti-HIV treatment for the first time is the NNRTI efavirenz (Sustiva) with the NRTIs tenofovir (Viread) and FTC (emtricitabine, Emtriva). Tenofovir and FTC come in a combined pill called Truvada or 3TC (lamivudine, Epivir ) and abacavir (Ziagen) in the combination pill Kivexa. Before taking Kivexa you need to have a special blood test to make sure that you are not allergic to abacavir. Kivexa might not be a good choice if you have a viral load above 100,000 or have a risk of heart disease.

After you’ve had an undetectable viral load for at least six months on the combination of efavirenz and Truvada you may be able to switch and take all three of these drugs in a single combined pill called Atripla.

An alternative to efavirenz is a boosted protease inhibitor. A boosted protease inhibitor could be a good option if you have resistance to NNRTIs or NRTIs. The preferred boosted protease inhibitors are Kaletra (lopinavir/ritonavir), fosamprenavir (Telzir)/ritonavir, or saquinavir (Invirase)/ritonavir. Atazanavir (Reyataz)/ritonavir and darunavir (Prezista)/ritonavir are also options but haven’t yet been approved for people taking anti-HIV treatment for the first time.

If you are thinking of becoming pregnant, then nevirapine (Viramune) is recommended. But women are advised not to start taking nevirapine if their CD4 cell count is above 250 because of a risk of serious side-effects. AZT and 3TC (Combivir) are recommended as the other two drugs for women considering pregnancy. These three drugs are recommended during pregnancy because they have been shown to be good at preventing mother-to-baby transmission of HIV.