When to start antiretroviral therapy: a swinging pendulum?

Abstract

Although early initiation of antiretroviral treatment has long been associated with some benefit over later initiation, the magnitude of the benefit is becoming better defined with longer follow-up of large numbers of patients in cohort studies. These benefits have become more evident in part because of improvements in efficacy, tolerability, and convenience of antiretroviral treatment regimens. The benefits also reflect growing recognition of the effect of such treatment in reducing risk of both HIV-related and non-HIV-related complications that are not associated with low CD4+ cell count. On balance, currently available information supports using a CD4+ count of 350 cells/microL as a general threshold for initiating treatment, with immediate treatment warranted for selected patients, including those with conditions for which antiretroviral therapy is the best or only treatment. This article summarizes a presentation on when to initiate antiretroviral therapy made by Joel E. Gallant, MD, MPH, at an International AIDS Society-USA Continuing Medical Education course in New York in October 2007.