Initiation of antiretroviral therapy

Until there is a therapy or a vaccine that can eradicate HIV infection, it is important to continue debating the issues of when and how to use the many antiviral agents licensed as initial treatment since there remain many areas of uncertainty.

Early initiation of treatment may be beneficial in terms of HIV progression but it has to be weighed against the risks of adverse drug side effects and complications. In first-line treatment the choice of nucleoside backbones has become limited due to the availability of once a day combined formulations which have excellent short and long-term side-effect profiles. Whether to use protease inhibitors or nonnucleosides as initial agents still awaits definitive data, but again once a day therapy appears to be the preferred option.

There are only a few initial treatment regimens which are convenient and well tolerated. Starting treatment early will only become a possibility if the agents used cause no long-term problems and no significant resistance. New agents are emerging but it is unlikely that they will manage to reach these exacting standards. There is a need for authoritative adherence research with the results being translated into general care.