Should I start antiretroviral medicines for HIV infection even though I have no symptoms?

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Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Treatment of HIV infection without symptoms (asymptomatic) with three or more antiretroviral medicines (combination therapy, or highly active antiretroviral therapy [HAART]) is based on:¹

• Your general health.
• Your CD4+ counts.
• Your willingness and ability to take your medicines as prescribed. Following your antiretroviral therapy schedule is essential for successful treatment of your HIV infection.

Treatment guidelines suggest the following for people with HIV:¹

• Experts currently consider your CD4+ cell count and presence or absence of symptoms much more important than your viral load, when considering treatment.
• If your CD4+ cell count is between 200 and 350 cells per microliter (mcL), you should be discussing treatment with your doctor to avoid letting your CD4+ cell count drop below 200.
• If your CD4+ cell count is more than 350 cells per microliter, treatment may be offered if you have mild (non-AIDS) symptoms of HIV infection, such as weight loss, fevers, or frequent yeast infections.
• If treatment is not started, your condition will be monitored with frequent CD4+ cell counts.
• If you have symptoms of HIV or AIDS, you should consider starting treatment, whatever your CD4+ cell count is.

Medical Information

What is human immunodeficiency virus (HIV)?

HIV is a virus that attacks and gradually weakens your immune system. HIV infects CD4+ cells, a type of white blood cell. As HIV-infected CD4+ cells are destroyed or impaired, the immune system becomes less able to fight infection and disease. HIV infection can progress to AIDS.

What increases my risk for HIV?

Most people get HIV by having unprotected sex with someone who has HIV. Another common way of getting the virus is by sharing needles with someone infected with HIV when injecting drugs.

You have an increased risk of developing HIV through sexual contact if you:

• Have unprotected sex (do not use condoms).
• Have multiple sex partners.
• Are a man who has sex with men.
• Have high-risk partner(s) (a man or woman who has multiple sex partners or injects drugs, or a man who has sex with men).
• Have or have recently had a sexually transmitted disease, such as syphilis or genital herpes.

People who are also at increased risk of developing HIV infection include:

• Those who inject drugs or steroids, especially if they share needles, syringes, cookers, or other equipment used to inject drugs.
• Babies born to women who are infected with HIV.

What are antiretroviral medicines?

Antiretroviral medicines are used to slow the rate at which HIV makes copies of itself (replicates) in the body. A combination of 3 or more antiretroviral medicines called highly active antiretroviral therapy (HAART) is the standard treatment for HIV infection. It is more effective than using just one medicine (monotherapy) in the treatment of HIV. This treatment approach offers the best chance of preventing HIV from multiplying and allowing your immune system to stay healthy.

How effective are antiretroviral medicines?

The goal of antiretroviral therapy is to reduce the amount of virus in your body (viral load) to a level that is low enough that it can no longer be detected by laboratory tests.

The use of 3 or more antiretroviral medicines (HAART) does not cure HIV infection. But people who are treated with HAART:

• Avoid developing AIDS, or recover from the symptoms of AIDS and enjoy a return to better health.
• Have fewer opportunistic infections that are more common in people who have weakened immune systems, such as certain types of pneumonia.
• Experience significant drops in their viral loads, often to the point that the virus can no longer be detected in their blood with currently available tests. This is the goal of treatment.
• Have a stable or slowly increasing CD4+ cell count.

From 1995 to 1996, the numbers of Americans who developed opportunistic infections or who died from AIDS declined for the first time in the history of the epidemic. In 1996, the widespread use of HAART began. Experts believe that the use of HAART is mostly responsible for the continuing decline of deaths from AIDS.²

What are the benefits of starting antiretroviral medicines before symptoms of HIV develop?

The advantages of beginning treatment with antiretroviral medicines (HAART) before HIV-related symptoms develop include:¹

• Increased ability to achieve and maintain control of viral replication.
• Delay or prevention of the weakening of the immune system. The risk of opportunistic infections—such as cytomegalovirus (CMV) infection, Mycobacterium avium complex (MAC), Pneumocystispneumonia, cryptosporidiosis, and AIDS dementia—decreases.
• Slower progression of HIV to AIDS.
• Lower risk of resistance to the medicines, if viral suppression is complete.
• Possibly lowered risk of HIV transmission.

  Note:

  Even with early therapy, the risk of HIV transmission still exists. Antiretroviral therapy cannot substitute for prevention measures, such as use of condoms and safe sex practices.

What are the risks of starting antiretroviral medicines before symptoms of HIV develop?

Not all the risks of starting antiretroviral therapy before HIV-related symptoms develop are known. The disadvantages of beginning treatment with antiretroviral medicines (HAART) before HIV-related symptoms develop include:¹

• Greater chance of serious medicine-related problems and side effects.
• Earlier development of resistance to the medicines if viral suppression is not complete.
• Limitation of future antiretroviral treatment options.
• Cost of medicines, which may cause a financial hardship.

What are the benefits of waiting until symptoms of HIV develop before starting antiretroviral medicines?

The advantages of delaying treatment with antiretroviral medicines (HAART) until HIV-related symptoms or AIDS develops include:¹

• Avoiding serious medicine-related problems and side effects.
• Delaying development of resistance to the medicines.
• Preserving the maximum number of antiretroviral medicine options when HIV disease risk is highest.
• Saving money by not having to buy expensive anti-HIV medicines.

What are the risks of waiting until symptoms of HIV develop before starting antiretroviral medicines?

The possible disadvantages of delaying treatment with antiretroviral medicines (HAART) until HIV-related symptoms or AIDS develops include an increased risk of:¹

• Illness or death due to a weakened immune system.
• Not controlling the amount of virus in your blood.
• Spreading HIV to others.

For more information, see the topic Human Immunodeficiency Virus (HIV) Infection.

Your Information

Your choices are:

• Start treatment with antiretroviral medicines (HAART) before HIV-related symptoms develop.
• Delay treatment with antiretroviral medicines (HAART) until HIV-related symptoms or AIDS develops.

The decision about whether to start antiretroviral medicines (HAART) takes into account your personal feelings and the medical facts.

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help make your decision. After completing it, you should have a better idea of how you feel about starting antiretroviral medicines (HAART). Discuss the worksheet with your health professional.

Circle the answer that best applies to you.

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to start or not start antiretroviral medicines (HAART).

Check the box below that represents your overall impression about your decision.

Return to the topic Human Immunodeficiency Virus (HIV) Infection.

References

Citations

1. U.S. Department of Health and Human Services (2006). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Adult and Adolescent Guidelines. Available online: http://www.aidsinfo.nih.gov/guidelines.

2. Centers for Disease Control and Prevention (2003). HIV/AIDS Surveillance Report, 15. Also available online: http://www.cdc.gov/hiv/stats/hasrlink.htm.

Credits

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Last updated:	June 06, 2007
Author:	Maria G. Essig, MS, ELS
Reviewed By:	Adam Husney, MD - Family Medicine, Peter Shalit, MD, PhD - Internal Medicine
Editors:	Susan Van Houten, RN, BSN, MBA, Pat Truman