When to start antiretroviral treatment: a changing equation.

The decision about when to start antiretroviral treatment is among the most vexing puzzles in the field of HIV management.HIV begins killing CD4 T-cells--key players in the body's immune response--from the time of initial infection, yet many HIV positive people go for years without experiencing clinical symptoms. Antiretroviral drugs effectively suppress viral replication and enable CD4 cell recovery, but also can lead to side effects that are at best bothersome and at worst debilitating or even fatal. While the optimal time to begin treatment for many diseases is as soon as possible after infection, in the case of HIV the decision involves balancing the benefits of preventing immune system decline--as well as other harmful effects of HIV infection that are only beginning to be understood--against the inconvenience, expense, and health risks associated with antiretroviral therapy.