High active antiretroviral therapy (HAART) can save life of a lot of HIV/AIDS patients. It is the standard of care for HIV infection.
However, HAART has serious side effects and drug-resistance for HIV. It needs HAART intervention adherence, life-long and there is no cure.
In order to better serve HIV infected patients, we argue which is more effective? Early treatment (as soon as HIV diagnostics) or later treatment (patient CD4 is greatly declining)?
It needs further investigation. No single modality can be fully reliant.
Newer recommendations are in favor of starting treatment early rather than waiting for the CD4 counts to fall. While considering risk vs. benefit ratios too it would seem advisable to not allow for the viral load to increase enough to cause opportunistic infections and for the patient to develop AIDS. Side effects can usually be managed or prevented by routine evaluations of parameters such as liver function tests. Further, the patient while seropositive with normal CD4 counts whether or not has progressed to AIDS is a source of infection to others.
Dear Dr. Da Yong Lu,
From a basic point of view, early initiation of ART might be desirable. A reduced CD4 count might mean not only the death of peripheral CD4+ T cells but also reduced production (thymic output) of CD4+ T cells. Once the latter occurs, it is not always recoverable by treatment. Therefore, at least those potential immunological nonresponders could be benefited by early ART.
An excellent explanation of the rationale for early and continuous treatment is given at http://hivmanagement.ashm.org.au/index.php/therapeutics-and-monitoring/antiretroviral-therapy (from paragraph 3). Essentially, this is associated with better clinical outcomes across various measures, as well as prevention of sexual transmission if viral suppression is achieved. Prevention of transmission ("undetectable = untransmittable", see https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable) assists the public health response and efforts to end the HIV epidemic (for example, UNAIDS targets). Apparently the most recent therapies have fewer side effects, and taking them consistently as prescribed reduces the risk of drug resistance (https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/56/drug-resistance).
I agree with Claire in principle and if we consider the biology of HIV. The key characteristics of the infection are chronic immune activation and inflammation. The lower the CD4 count, the more damage to an array of immune cells beyond just the CD4 subsets as well as to the lymph nodes, gut and nervous system. So earlier is better both for tolerating ARV side effects and limiting the immune damage. (As an aside, consider SIV-infected sooty mangabeys: they have an active infection, some loss of CD4 but don't develop AIDS; largely because they don't suffer the chronic immune activation.)
That all said, there are other key pieces. Where is the patient psychologically? Are they ready for daily meds? (It may NOT be life long if either a good preventive vaccine is developed, a cure and/or longer lasting ARV injections, for example.)
If the answer is yes, I'd say start as soon as the HIV diagnosis is in.
The other horror of the AIDS pandemic is that the entrenched racism of our world leads to a lack of continuity of care for poor people--and disproportionately lousy care for people of color in the US--and that millions in Africa lack access to ARV. Let alone the ongoing economic genocide committed by the greed of pharma that evergreens patents and maintains ludicrously high prices for no reason but sheer murderous greed. EVERY ARV currently approved in the US and EU SHOULD be available at cost so relevant governments and agencies can get treatment to all who need it.
Finally--a brief plug for sanity. There are MANY traditional interventions and micronutrient therapies that a) may slow disease progression (though nothing I've seen works as well as ARV) and b) may offset GI side effects, liver and kidney toxicities and so forth. These should be considered. If it works, it is medicine, regardless of arbitrary designations of provenance.
I agree with George and Claire that early treatment is important and also early detection is more important
As it is already known HAART is the recommended treatment for HIV infected people in which it have better treatment outcome when it have been initiated as early as possible for better viral load suppression and increased CD 4 count. early initiation of ART increases the quality of life as well decreases the transmission especially in case of mother to child transmission/PMTCT/ . In addition to HAART considering ARV as a prophylaxis's for HIV exposed infants and child will have a significant importance to get HIV free generation.
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