Timing of antiretroviral therapy: an immunological perspective

The success of an effective antiretroviral therapy regimen depends upon its effects on the viral load, the CD4 T-cell count and the ability to preserve and/or restore useful HIV-1-specific immune responses. Many new problems that limit the effectiveness of current treatment are arising during comparison of the differing positions taken in the British and American guidelines. A further difficulty is that many patients present for the first time in the clinic with AIDS-related illness and profound immunosuppression. Pitfalls such as a failure to eradicate the virus, the induction of side effects and a lack of regeneration of HIV-1-specific responses require frequent updates of the guidelines and reviews of the timing of initiation of effective antiretroviral therapy and of strategies for optimising the long-term success of antiretroviral therapy. Treatment guidelines encompass the choice of initial and subsequent regimens, treatment successes and failures, the timing of treatment and, finally, lay down the foundations for promising immune-based therapies and future drug regimens.