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When to start antiviral therapy

Guidelines for starting antiviral therapy have been proposed by panels of experts from the DHHS and the IAS.- They recommend treating all patients who have symptoms and those who have CD4 cell counts of less than 200, and, perhaps, 350 cells per mm3 or in those with higher viral loads. Of late, there has been a trend towards focusing more on CD4 cell counts than viral loads in making the decision as to when therapy should be started in asymptomatic individuals. The DHHS guidelines have suggested that therapy be considered even in those with higher CD4 cell counts if viral load is greater than 100,000 copies per mL, or, at least, that CD4 cell counts be followed more closely in this group. The IAS-USA guidelines have tended to use a viral load cutoff for considering therapy in asymptomatic individuals with CD4 cells greater than 100,000 copies per mL. However, it should be kept in mind that the risk of developing short- and long-term toxicity from treatment, and the problem with getting patients to adhere to treatment, are major limitations of therapy that need to be considered before treatment is initiated in order to optimize the chances of success and to avoid the development of drug resistance. Other authorities, therefore, have proposed delaying therapy until the viral load is even higher. Regardless, all agree that HIV is a slowly progressive disease, and therapy rarely needs to be started abruptly. Therefore, there usually is time for each patient to carefully consider options prior to starting treatment.

Before starting treatment, patients must be aware of the short and long-term side effects of the drugs, including the fact that some long-term complications may not be known. The patients also need to realize that therapy is a long-term commitment and requires an extraordinary level of adherence to the regimen of drugs. In addition, clinicians and patients should recognize that depression, feelings of isolation, substance abuse, and side effects of the antiviral drugs can all be associated with the failure to follow the treatment program.