Strategies for first line HIV therapy

May 2008     View PDF     En español

Treat early? A discussion

The best time to start therapy remains one of the major unanswered questions in HIV disease. There are two major obstacles to answering this question: one philosophical and one practical. Philosophically, there’s no consensus that even one recommendation would be appropriate for all, or even most, people with HIV. The important factors that guide treatment decisions can vary greatly from person to person. No recommendation, or set of them, could possibly account for this. Others would counter that broad recommendations could nonetheless help guide and inform anyone making the decision to start therapy.

However, there’s a practical issue at hand. Treatment recommendations must be guided by data. The gold standard of bio-medical research is the prospective, randomized, controlled study. No such study exists on the question of when to start, and designing and implementing one is challenging. They would need to be large and long-term to gain useful information. Then, this begs the usefulness of the data once the study is done. For example, if a “when to start” study had been done in the late 1990s, final data would just now be reportable. We would have a lot of information on Crixivan, Viracept and Zerit regimens. But how helpful would that be given the range of drugs now available?

In addition to protecting the health and well-being of the person living with HIV, HIV treatment also reduces the risk of transmission. While treatment decisions should be primarily guided by the needs of the person living with HIV, the health and well-being of their partners and the larger community can also benefit. This could be particularly important for mixed status couples or people with multiple sexual partners.