The decision to start therapy should be made after considering the patient's acceptance or readiness and the probability of adherence. The strength of the recommendation is dependant on the prognosis as determined by clinical state, CD4 cell count and viral burden.
Table showing when to start therapy.
Indication for the initiation of Antiretroviral Therapy in the Chronically HIV-1 infected patient
Clinical Category |
CD4+ Cell Count |
Plasma HIV RNA |
Recommendation |
Symptomatic (AIDS, Severe symptoms) |
Any Value |
Any Value |
Treat |
Asymptomatic AIDS, |
CD4+ cells<200/mm3 |
Any Value |
Treat |
Asymptomatic |
CD4+ cells>200/mm3 but < 350/mm3 |
Any Value |
Treatment should generally be offered, though controversy exists |
Asymptomatic |
CD4+T cells >350/mm3 |
>30,000(bDNA) or >55,000(RT-PCR) |
Some experts would recommend initiating therapy, recognizing that the 3 year risk of developing AIDS in untreated patients is >30%. In the absence of very high levels of plasma HIV RNA, some would defer therapy and monitor the CD4 + cell count and level of plasma HIV RNA more frequently. Clinical outcomes data after initiating therapy are lacking. |
In resource poor setting, initation for symptomatic patients can be started even when CD4 or viral load assessment tools are absent. The two assessments tests are, however, useful for monitoring therapy.
Initiating Therapy in established HIV infection
Before initiating therapy in any individual the following basic evaluation should be performed
• Complete history and physical examination
• Total blood count, Urea and electrolytes and liver function tests.
• CD4 (T-lymphocyte count)
• Viral load (Plasma HIV RNA)
Additional investigations should be targeted towards establishing factors leading to symptomatology including common opportunistic infections such as Tuberculosis, Cryptococcal Meningitis and Atypical pneumonia's. It may also be advantageous to follow lipid profiles in most patients on antiretroviral therapy.
Initiating Therapy in Patients with Asymptomatic HIV infection This is still controversial. A few facts however are well known:-
• If the CD4 count falls below 200 then one is bound to suffer increasing incidences of opportunistic infections
• Although there is theoretical benefit to antiretroviral therapy for patients with CD4T cell counts greater than 200 cells/m3, no studies have been conducted to compare immediate against delayed potent therapy.
• The optimal time to initiate antiretroviral therapy is not known.
One should therefore weigh the risks and benefits of delayed and early therapy and discuss them fully with the patient before initiating therapy. These risks and benefits are as outlined in the table.
