Current issues in initiation of antiretroviral therapy

Initial therapy for patients with HIV infection is becoming increasingly simple and well tolerated. Effective and durable therapy can now be achieved with a regimen that consists of just 2 pills dosed once a day without food restrictions, and it is anticipated that we will soon have a potent HAART regimen contained in a single pill. Therapy - including the decision of when to start - must always be individualized to maximize the likelihood of a durable response. Published guidelines agree that therapy should be started for any patient with symptomatic disease or AIDS and for asymptomatic patients with CD4⁺ cell counts below 200/μL, but there is an increasingly strong rationale for earlier initiation of therapy. Preferred starting regimens include either a nonnucleoside reverse transcriptase inhibitor or a protease inhibitor as an "anchor drug," combined with 2 nucleoside analogs.