When to Start Antiretroviral Therapy and What to Start With-- A European Perspective

Although antiretroviral combination therapy has greatly improved the life expectancy of HIV-infected individuals, its use is hampered by considerable toxicity, the need for life-long near-perfect adherence to strict dosing regimens in order to avoid the emergence of drug resistance, and high cost. In this paper we review current understanding of when to best initiate antiretroviral therapy and what regimen to start with. The limitations of antiretroviral combination therapy are increasingly clear, and this has led to the current tendency to delay the initiation of therapy until CD4 cell counts have consistently dropped toward the 200 cells/mm(3 )mark, or until plasma HIV-1 RNA has increased to above 100,000 copies/mL. The need for optimal adherence also implies a "readiness" on the part of the patient to start treatment. Once the decision to commence therapy has been reached, what particular combinations of drugs to start with increasingly demands an individualized approach.