Initiation of Antiretroviral Therapy in HIV

Peter L. Salgo, MD: Let’s talk about initiating treatment. Somebody has HIV and you’re going to initiate treatment. What are you looking to do? What are your goals?

Joseph Eron, MD: So the goals are, I think, really straightforward. It’s to either maintain, or restore, health. That’s the goal. To do that, we focus on getting people’s viral loads suppressed. And you want to do it with the safest, most tolerated therapy possible. But we’re really just trying to either maintain health (if their CD4 is already high) or restore health (if their CD4 is low). I think that’s the simple answer.

Peter L. Salgo, MD: Okay, that’s it? We want to make them better?

Joseph Eron, MD: Right.

Paul E. Sax, MD: You’re basically choosing a regimen that’s going to suppress viral replication. We’re lucky. We have a phenomenal surrogate marker for HIV health, and that is that suppression of viral replication with antiretroviral therapy correlates so strongly with good outcomes. If you can do that, you’re golden.

Joseph Eron, MD: And that’s why everybody is focused on viral load. The patients are focused on viral load. The doctors are all focused on viral load. But my point is just that the goal is to keep people healthy.

Peter L. Salgo, MD: There’s always these 2 markers that everybody is talking about. One is the CD4 count and one is the viremia.

Ian Frank, MD: Viral load.

Peter L. Salgo, MD: Viral load. What’s the difference? Virus in your blood. Viral load. What’s the difference?

Ian Frank, MD: I think that the providers would say viral load. But you’re right. Viral load is the amount of viremia.

Peter L. Salgo, MD: Is it better to look for viremia (or viral load) or CD4 count? Or do you use both?

Joseph Eron, MD: The thing is, you can’t really do anything about CD4 cell count. You can suppress the viral load, and in most people, their CD4 count goes up—and that’s a good thing—or virtually everybody is stable. There are some people who you suppress their viral load and their CD4 doesn’t go up or it goes up as much as you expect.

Eric S. Daar, MD: We do know what to do with CD4s, and we know that when they’re below certain thresholds, we give antibiotics to prevent them from developing opportunistic infections.

Paul E. Sax, MD: But Joe is right. I was invited to give a lecture at another academic medical center in Boston. They said, “We want you to talk about people whose viral load is suppressed, but whose CD4 cell count hasn’t recovered.” And I said, “That’s going to be a very short talk. We don’t know what to do about those people. Changing therapy doesn’t really help.”

Peter L. Salgo, MD: So, you initiate therapy when there is virus in the blood or when the CD4 count is low?

Paul E. Sax, MD: Either one.

Peter L. Salgo, MD: Either one, period.

Ian Frank, MD: Wait. We are no longer considering CD4 count when making the decision to initiate therapy. Right now, the standard procedure is that everybody with HIV—if their viral load is measureable, which is almost everybody with HIV—should be started on therapy.

Peter L. Salgo, MD: So, you don’t wait for the CD4 count?

Ian Frank, MD: We want to get the CD4 count because, initially, we’d like to understand if they’re at risk for opportunistic infections. We don’t have to choose between getting a viral load or a CD4 count before starting therapy—we can do both, and we do. The CD4 count tells us if you are at risk for an opportunistic infection now. And the viral load is telling us, “Okay, here’s the starting point.”

Peter L. Salgo, MD: They’re 2 different classes of information?

Ian Frank, MD: Yes.

Paul E. Sax, MD: The CD4 cell count also gives you a sense of urgency. So, when we have a newly diagnosed patient and their CD4 cell count is, for example, very depleted (ie, under 100, under 50), even if they’re feeling relatively well, we essentially tell those patients, “This is your job to start antiretroviral therapy. This is your top priority.” Because in the old days, those are the people who had a prognosis kind of like acute leukemia. They were the ones who died within 6 to 18 months. They have to go on treatment immediately. So, for the patients with higher CD4 cell counts, we like to start them soon, as well, but it’s not quite so easy.

Peter L. Salgo, MD: Why would you not start them on the day of diagnosis?

Joseph Eron, MD: Well, that’s a great topic and an area of research. There are several studies now that suggest that if you actually start people on their day of diagnosis, maybe they actually return to care better, suppress faster, and retain care better. You’re telling someone, “You have a serious illness” and “Oh, by the way, we’ll start therapy the next time we see you.” But the flip side to that is, of course, that it’s complicated to start therapy. You need to know some stuff about people, and you want to make sure they take it correctly. So, it’s a big step, and you have people that push back.

Peter L. Salgo, MD: What about starting therapy after infection, prior to antibody detection?

Joseph Eron, MD: Yes. Different story.

Paul E. Sax, MD: That’s a different story. I’d like to just mention one other thing about same-day starts. I think the reason we didn’t start therapy on the same day as diagnosis in the old days was because the regimens were very complex. An entire industry was built creating education about taking antiretroviral therapy and what it means to take medicines with and without food, as well as what time of the day to take them. There were these counselors. You have to come back and go to adherence class, and you have to come back and understand what viral load and CD4 means. All of that stuff, today, is antiquated—we don’t need that anymore. Basically, people can take 1 or 2 pills a day and they’re fine. So right now, same-day starts make a lot of sense.

Peter L. Salgo, MD: That’s astounding. There’s no excuse not to get on the ball here.

Eric S. Daar, MD: There are practical issues, though, that we all have to deal with. Not everybody comes to us with insurance. Not everybody comes to us who can literally have a prescription written and get the drugs that day. And not everybody who comes in, often having just found out about this diagnosis, is ready to leave with pills that day. So, there may be advantages for select patients to do this, if you can. Otherwise, it’s as soon as it’s feasible to get people on treatment.

Transcript edited for clarity.