When to start treatment

A number of factors will influence your decision on the best time for you to start antiretroviral [1]A medication or other substance which is active against retroviruses such as HIV. therapy (ART).

There are clinical [2]Pertaining to or founded on observation and treatment of participants, as distinguished from theoretical or basic science. markers to consider, namely your CD4 count and viral load [3]A measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma.. There are a range of opinions about the exact time that people should start ART, but the trend is now favouring earlier treatment.

Recent studies are showing that people who commence ART earlier have better health outcomes, so many experts now believe that all people with a CD4 count of 500 and below should be on treatment. Other clinicians go further and believe there are benefits in starting treatment even earlier: above a CD4 count of 500, including as soon as HIV infection is diagnosed. For those people who have HIV related symptoms, treatment is usually recommended irrespective of CD4 count.

Your age and whether you have any other health issues also influences when you should start taking HIV medications. Older people and those with hepatitis, for example, often choose to start treating their HIV as soon as possible as ART can also protect you from developing other illnesses.

We know that treatment reduces viral load and therefore lessens the risk of transmitting HIV, so these other protective benefits to consider for the personal protection of your partner and, for pregnant women, your baby.

But possibly the most important factor that will influence the decision on when you start will be your motivations to decide to include pill-taking into your daily routine. Antiretroviral therapy has become more manageable in recent years, but it is still currently a life-long commitment and you should only commence it when you are ready.

Factors to consider

Antiretroviral guidelines and observational studies

In Australia, the HIV antiretroviral treatment guidelines which are generally followed are those from the US Department of Health and Human Services (DHHS). An Australian panel provides a commentary on the US guidelines reflecting local issues, technicalities and drug availability.

The most recent DHHS guidelines recommend treatment for ALL people regardless of CD4 count.

Research is ongoing to better understand if starting at one CD4 count has major advantages than another—for example, as soon as you want to, rather than waiting for your CD4 levels to fall.

Your doctor will be aware of new developments in the clinical research, so don’t be afraid to ask questions and also do your own reading.
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CD4 count

CD4 cells play an important role in our immune response. A normal count is between 500 and 1200, but many people with HIV remain healthy with counts below 500.

The reason people living with HIV experience a drop in CD4 count is because HIV uses these particular blood cells to reproduce then kills them off, and therefore over time the count goes down.

CD4 counts fluctuate during the day and also respond to other infections like the flu and Sexually Transmitted Infections (STIs [4][Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). ), stress, poor diet, some vaccinations and smoking. It is important to monitor trends and not to become overly concerned about individual results. If you do experience a significant drop your doctor will normally repeat the test.

People who start treatment when their CD4 count is higher tend to experience fewer health issues, such as diseases of the heart, liver [5]A large organ, located in the upper right abdomen, which assists in digestion by metabolising carbohydrates, fats and proteins, stores vitamins and minerals, produces amino acids, bile and cholesterol, and removes toxins from the blood., kidneys and other organs, diabetes [6][Diabetes mellitus] A disorder in which sugars in the diet cannot be metabolised into energy due to a lack of the enzyme insulin. Late-onset diabetes mellitus may be a long-term side effect of some anti-HIV drugs., cancer and brain function.
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Viral Load

Your Viral Load (VL) is the measure of the amount of HIV in your blood. Results are given as ‘copies’ of the virus [7]A small infective organism which is incapable of reproducing outside a host cell. per ml of blood.

During seroconversion, or soon after you have been exposed to HIV, your VL increases dramatically and then drops in response to the immune system. We can ‘map’ this by monitoring our CD4 cells, which initially drop after exposure to HIV then recover.

Your VL and CD4 count will then remain relatively stable for a while. This is called the ‘latency period’ and differs between individuals, but most often lasts for several years.

There are three different grouping levels of VL:

10,000 copies per ml of blood or less is considered low
100,000 copies per ml of blood or less is considered moderate
Over 100,000 copies is considered high

To date, most people with HIV are recommended to start treatment in the moderate range. When the level of virus is in the high range, especially for a long period of time, it can cause damage to your heart, blood vessels, kidneys, liver, brain and cause symptoms such as fatigue, memory problems, joint pain, skin rash and digestive problems.

A high viral load also stimulates your immune system into releasing what is called an ‘inflammatory response’. This is a normal function of the immune system in response to infection.

The immune system sends out cells, called pro inflammatory cytokines that cause inflammation to help control infection, which is why you feel stuffy and look red when you have a cold.

However when released continuously, as is the case with HIV, these cytokines are thought to cause damage to other parts of the body and contribute to the health issues already mentioned.
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Age and other health issues

People who are around 50 or older when they become HIV positive may be recommended to start treatment sooner while their clinical markers are good.

Starting treatment sooner can help prevent and slow health issues seen more in this age range, for example heart disease, diabetes, arthritis and cancer.

People with other chronic health issues like hepatitis may also choose to start ART sooner. If you are living with hepatitis and HIV then starting treatment sooner will help prevent a number of health issues that you can develop, including maintaining the health of your liver.

Some HIV treatments are also effective against some forms of hepatitis so talk to your doctor about what would be most beneficial to you.

People with HIV may experience health issues related to HIV even if their blood counts are considered ‘OK’. Some people may choose to start treatment sooner than others in order to treat HIV and the health issues.
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Sex

People living with HIV who have sex with a person who does not have HIV may consider starting treatment sooner than might otherwise be suggested.

Starting treatment can be one of a number of strategies you can adopt to prevent the transmission of HIV to your partner or others. However, treatment alone may not prevent the transmission of HIV to others.

Condoms and water based lube for penetrative sex, vaginal or anal, is added protection against passing on HIV.
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PEP (Post Exposure Prophylaxis)

Sometimes, even with the best planning, condoms, lube and ‘technique’, accidents and slip-ups can still happen.

Should you forget to use a condom, or if it breaks or something else happens that you think may have exposed your sexual partner to HIV you should encourage them to take PEP.

PEP is a special combination of HIV treatments that are given to people who have been exposed to HIV to prevent them from becoming HIV positive.

It takes time from when HIV enters the body until it ‘embeds’ itself into the immune system. If PEP treatment is started during this time the medication can prevent HIV from taking hold, and prevent someone from becoming HIV positive.

For more information call 1800 PEP NOW (NSW) or go directly to an HIV specialist. They can be found in Sexual Health Clinics, GP Clinics who see people with HIV and the Emergency Departments of Major Hospitals.

To be effective PEP must be started within 72 hours of exposure to HIV, and the sooner PEP is started, the better chance it has to work.
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Conception, pregnancy and childbirth

Women living with HIV who are considering pregnancy or who are pregnant may be encouraged to take treatment to help prevent HIV being passed on to the baby.

Treatment can be started at any time during pregnancy, however some treatments are safer for the baby’s development in the uterus than others, so specialist advice is vital.

During childbirth women living with HIV can be given HIV treatments intravenously, through a ‘drip’ in the arm [8]Any of the treatment groups in a randomised trial. Most randomised trials have two "arms," but some have three "arms," or even more. to help prevent HIV being passed onto their baby—this treatment is not always given, however.

After birth the baby can also be given HIV treatment in liquid form to further prevent the risk of acquiring HIV. This technique is commonly used and very safe for both mother and baby.
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When you are ready!

Whatever your blood count, health issues or plans for a family, the best time for you to start treatment is when you are ready.

Starting treatments with HIV drugs is a daily commitment to taking your medication on time, every time.

Even though newer combinations require fewer pills and don’t always need to be taken at exactly the same time each day, persistence and adherence with a combination that suits you and works for you is your key to living a long and healthy life.

There is good evidence that people living with HIV who have prepared for treatment by researching, talking with their doctor and other HIV service providers, and thinking about how they will fit treatments into their daily routine, usually have the best treatment outcomes and experience much less stress in the lead up to starting on the therapy.

Start talking to people and reading up – and remember that not all information on the web is accurate or current – so always discuss information with a qualified health care worker or your doctor.
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