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Factors to consider before starting antiviral therapy

One of the most controversial areas in the management of HIV disease is deciding the best time to start antiviral treatment. Clearly, therapy during the mildly symptomatic stage of the disease delays its progression to AIDS, and treating individuals with AIDS postpones death.

Consequently, most experts agree that patients who have experienced complications of HIV disease, such as oral thrush (yeast infection in the mouth), chronic unexplained diarrhea, fevers, weight loss, opportunistic infections, or dementia (for example, forgetfulness) should be started on antiviral treatment even if the symptoms are mild.

In patients who do not have symptoms, however, there is more uncertainty. Most recommendations for this group are based on the predictors of clinical progression, such as the number of CD4 cells and the viral load. Thus, several studies have demonstrated an increased risk of disease advancement in individuals with a CD4 cell count of less than 200 to 350 cells per mm3.

Similarly, those with elevated viral loads, regardless of the CD4 cell count, are at increased risk for disease progression. Debate continues, however, regarding the best threshold level at which to set the viral load to trigger the beginning of drug treatment.

In fact, it is likely that there will never be a proper study to answer this question. Therefore, the decision as to when to start treatment continues to be individualized, balancing the known benefits of therapy versus the risks, such as toxicity and the potential development of drug resistance.

One can envision that as treatments become easier to take, better tolerated, and increasingly effective, that therapy will begin to be started earlier in the course of infection.