[When to initiate antiretroviral therapy and what to start with?]

The decision to initiate antiretroviral therapy is influenced by the assessment of potential benefits and risks associated with early versus deferred therapy. The potential risks of deferred therapy include the increase probability of progression to AIDS, and the possibility that damage to the immune system would be irreversible. The potential benefits of deferred treatment are avoidance of drug-related toxicities and treatment-related negative effects on quality of life; preservation of treatment options, and more time for the patient to have a greater understanding of treatment demands. Once the decision is made, the primary goals of antiretroviral therapy are to reduce HIV-related morbidity and mortality, improve quality of life, restore and preserve immunologic function, and maximally and durably suppress viral load. However, regimen selection should be individualized, taking into consideration a number of factors such as pre-treatment viral load and CD4 lymphocyte cell count, co-morbidities, adherence potential, dosing convenience regarding pill burden, potential adverse drug effects, and potential drug interactions with other medications.