When and where to start: guidelines for the initiation of antiretroviral therapy

Although several sets of treatment guidelines recommend when antiretroviral therapy should begin, no overall consensus has emerged. Factors that must be weighed in deciding when to start include not only CD4+ cell count and viral load but also the stage and tempo of the disease and the commitment of the patient. Evidence suggests that a first-line, triple-nucleoside regimen may not be the best option, especially for people with more advanced disease. Although deciding between a protease inhibitor (PI) regimen and a non-nucleoside regimen is more difficult, some data indicate that PIs may exert beneficial effects not seen with other antiretrovirals. Simplifying regimens by combining agents with longer half-lives, or by combining two PIs, can make antiretroviral therapy easier to take and more tolerable. But no current regimen will be durable without the utmost adherence by the patient.