Choosing a treatment strategy

There are many factors to consider when choosing a combination antiretroviral regimen, including:

• HIV viral load
• CD4 cell count
• Overall health
• Opportunistic illness
• Treatment history
• Drug resistance
• Side-effects
• Adherence

The immediate aim of antiretroviral therapy is two-fold: suppressing HIV viral load as low as possible and restoring immune function, as indicated by a rising CD4 cell count. There is no dispute that the ultimate long-term goal of HIV treatment is to maintain good health, improve quality of life and extend survival, but there remains considerable debate about the best way to achieve this.

Current European and US HIV treatment guidelines recommend starting therapy once the CD4 cell count falls into the 200 to 350 cells/mm³ range. Treatment should be considered sooner if a person has symptoms of disease progression or immune deficiency, and possibly if they have a high viral load.

Over the course of the epidemic, research has provided conflicting data about the best time to start treatment. The ‘hit early, hit hard’ approach was popular in the late 1990s, but fell out of favour as it became clear that antiretroviral therapy can cause worrisome long-term side-effects such as metabolic abnormalities. In the mid-2000s, evidence began to accumulate that starting therapy earlier may indeed be beneficial, and the pendulum may be swinging back.

In any case, the benefits of treatment must be balanced against the drawbacks long-term toxicity, cost and impact on quality of life.

For further information about when to start treatment and which drugs to choose, see Starting HIV Treatment.

Using current antiretroviral drugs, HIV cannot be completely eradicated from the body, and treatment will probably need to be life-long. But individuals who are already using HAART also have options to consider, including sticking to a tried-and-true regimen or switching to another combination that might provide more potent viral suppression, fewer side-effects, improved convenience or lower cost. With more than 20 antiretroviral drugs approved for marketing or available through expanded access programs, there are now many choices for constructing effective combination regimens.

Researchers have explored various treatment strategies, include regimen simplification, induction and maintenance therapy, alternating between two or more combinations and structured treatment interruption. However, the safety and effectiveness of these approaches have not yet been proven in clinical trials.

For further information on switching regimens, see Changing HIV Treatment.