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Strategies for first line HIV therapy

May 2008 View PDF En español

Things to think about

If HIV drugs were easy to take, free from side effects and always worked in spite of resistance, then making decisions about when to start would be easy. While none are ideal, HIV medicines have improved over time, making them easier to take and generally more tolerable. The trick is to balance the benefits of reducing your HIV level and increasing your CD4 count along with the risks of side effects and treatment failure. These examples help make dealing with this struggle clearer. Each has its own possible benefits and disadvantages. These pros and cons are explained, but the only “right” answer for your situation comes from carefully considering both sides.

EXAMPLE 1: Acute or primary infection
A man knows that he was exposed to HIV several weeks ago. His HIV level is 600,000, but he continues to test negative on antibody tests. This indicates that he’s in the acute or primary stage of HIV infection. His doctor says that he should start treatment immediately and only has days to decide. Should he start now?

The pros
No data prove that starting now results in a longer, healthier life. However, some researchers suggest that early treatment may:

decrease the severity of the acute syndrome;
change the initial viral set point, which is shown in some research to affect the rate of disease progression;
keep HIV from changing (mutating) around the body’s defenses;
preserve immune health; and
prevent HIV from damaging tissues and cells due to inflammation.

The cons
These points are less theoretical and include the possibility that a person will:

have to take therapy indefinitely;
go through his or her treatment options too quickly; and
develop long-term side effects.

EXAMPLE 2: CD4 cell count between 350 and 500
A woman, who has been HIV-positive for ten years, has watched her CD4 count decline from 550 to 475 to 380 over 6 months. However, her HIV level is relatively stable around 15,000. She’s scared about side effects and hesitant about starting therapy. Should she start now or wait to see what happens with these two markers?

The pros
If she starts now:

She may reduce her risk of getting sick within the next three years.
She may have a stronger and more durable response to therapy.
She’s less likely to face significant side effects if she starts with a higher CD4 count.

The cons
If her fears are strong enough:

She may find it difficult to stay on her regimen.
Starting now may reduce the risk of disease progression in the short-term, but it may not hold up over time. The risk for treatment failure from drug resistance and/or side effects increases with each year on therapy.

EXAMPLE 3: CD4 cells over 500 with low HIV level
A man finds out that he’s HIV-positive. He reads a lot of literature on the Internet and gets excited about some of the newer experimental drugs. His CD4 count is 650 and his HIV level has never been above 4,000 on 3 tests over the last 6 months. He wants to fight his HIV aggressively and would like to try therapy. Should he start?

The pros

Starting this early may theoretically lead to long-term benefits in his immune health, may protect his organs from damage caused by inflammation and might prevent the development of viral diversity. However, the possible benefits have not been proven when taking treatment in earlier disease.

The cons.

Treatment started at this point may have to be taken for life and could lead to him running out of options sooner.
The risks for treatment failure from drug resistance and/or side effects increases with each year on therapy.

EXAMPLE 4: Having both HIV and hepatitis C
A woman has lived with HIV for more than ten years. She also has had hepatitis C (HCV) for 20 or more years. She recently found out she has significant liver damage. Liver function tests and a biopsy show that the HCV is causing this damage. She has never been on HIV or HCV therapy. Her CD4 count is 400 and HIV level is 80,000. Should she start HIV therapy now or wait until after she has tried to treat the HCV?

The pros

Starting HIV therapy now will reduce the risk that her CD4 count will drop and lead to an AIDS-related infection.
HIV therapy works as well in people with HCV as in those who do not have HCV.
HIV therapy can be well tolerated by people with HCV.

The cons