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When to Start Treatment

Overarching principles  

Positive Women Victoria recommends using the following principles to guide your decision to start treatment: 

  • It is every woman's right to decide whether or not to take HIV treatment 
  • The decision to start ART should be made by the individual with HIV, in consultation with her health care providers and on the basis that she is fully informed and supported in the decision making
  • The decision to start ART should take into account both personal health benefits and risks, and reduction in transmission risk 

Who should start treatment?  

Treatment with ART is recommended for everyone infected with HIV. ART helps people with HIV live longer, healthier lives and reduces the risk of HIV transmission, but the effectiveness of treatment depends on medical adherence. Before starting ART, it is important to deal with any issues that can make it difficult to take medication every day exactly as prescribed. For example, some medications may require you to eat at certain times of the day, and some have to be taken more than once a day at specific times. This can be even more challenging if you are currently taking prescription medication for unrelated conditions and can not take your HIV medication at the same time, or within hours of your current medication. For many people, starting ART means they have to make significant changes in the way they live and it's important to discuss all of these issues with your health care provider BEFORE you begin treatment. 

Ultimately, you and your health care provider will have to decide what is right for you based on your unique needs and circumstances, but HIV experts recommend you start treatment if any of the following applies to you:

  • You are experiencing severe symptoms of HIV 
  • You have an opportunistic infection
  • Your CD4 count is 350 cells/mm3 or less
  • You are pregnant
  • You have HIV-related kidney disease   

When to start treatment  

The Australian/US Treatment Guidelines recommend treatment between 350-500 CD4 counts, although at the 7th International AIDS Society Conference in 2013 the World Health Organisation introduced a new global recommendation that all HIV-positive people are offered treatment when their CD4 counts falls below 500, even if they are feeling well. In May 2015, a major international HIV treatment trial showed that immediate treatment of HIV, regardless of CD4 count, is clinically superior compared with deferred treatment among people with HIV infection and early disease.   

What other factors influence the decision to start ART?  

Whether - or when - you start HIV treatment and which type of treatment you will need depends on many factors, including:

  • Your CD4 count and viral load
  • Whether you have other conditions or co-infections, including pregnancy, an HIV-related illness, hepatitis C or AIDS
  • Your ability and willingness to commit to lifelong treatment with HIV medications
  • Your approach to reducing HIV transmission   

It is important to consider all of the above factors and be informed by the evidence when deciding whether or not to commence treatment, but remember, it is a personal choice. It may be helpful to hear from other women about their experiences with HIV treatment when making your decision. Positive Women Victoria can organise face-to-face or remote support in a safe, friendly and confidential environment.  

First-line drug combinations  

The first combination of drugs that a person takes is called first-line therapy. The Australian Treatment Guidelines currently recommend 10 possible combinations (each made up of 3 drugs) to start with:

  • Atripla (efavirenz/tenofovir/emtricitabine)
  • Truvada plus ritonavir-boosted Reyataz (tenofovir/emtricitabine + atazanavir)
  • Truvada plus ritonavir-boosted Prezista (tenofovir/emtricitabine + darunavir)
  • Truvada plus Isentress (tenofovir/emtricitabine + raltegravir)
  • Truvada plus Tivicay (tenofovir/emtricitabine + dolutegravir)
  • Kivexa plus Tivicay (abacavir/lamivudine + dolutegravir) – also available as 3 drug combined single pill Triumeq
  • Stribild (tenofovir/emtricitabine/elvitegravir/emtricitabine/cobicistat)

In addition to the above regimens, the following regimens are also recommended, but only for people with low viral loads below 100,000 copies:

  • Kivexa plus Stocrin (abacavir/lamivudine + efavirenz)
  • Eviplera (Truvada plus Edurant: tenofovir/emtricitabine/rilpivirine)
  • Kivexa plus ritonavir-boosted Reyataz (abacavir/lamivudine + atazanavir)

Alternative regimens can be prescribed but the above combinations are usually offered because they are easiest to take and tolerate, are less complicated and have the most convincing evidence for first-line use. Some drugs are not licenced for first-line treatment and are only prescribed when changing your current treatment.