Going on Treatment

Moisés Agosto Jonathan Timmes

How to decide when to start antiretroviral therapy and which drugs to take

November 28, 2016 • By Rita Rubin 

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Moisés Agosto learned he had HIV in 1986, years before there were any effective treatments. At the time, doctors told HIV-positive individuals they had maybe six months to live.


But he bucked the odds and survived. Now, as director of the treatment, education, adherence and mobilization division of NMAC (National Minority AIDS Council) in Washington, DC, the 51-year-old Agosto works to make sure that everyone with HIV has access to HIV care and treatment.


The World Health Organization and the U.S. Department of Health and Human Services recommend that everyone with HIV start antiretroviral (ARV) therapy as soon as possible.


The treatment landscape in 2016 is totally different from what it was when Agosto was diagnosed 30 years ago. Today, there’s an array of safe and effective HIV drugs on the market that are easy to take and have few side effects.


But you may wonder why you need to start treatment if you’re feeling fine and your immune system is still functioning at near-normal levels according to your CD4 cell count. CD4 cells, the primary target of HIV, coordinate how the immune system responds to infections. If your CD4 count—the number of cells in a cubic millimeter or milliliter of blood—drops below 200, you’re at a higher risk of experiencing an AIDS-related opportunistic infection, such as pneumocystis pneumonia. HIV medications prevent the virus from replicating in your body, which keeps your CD4 count up and your viral load (the amount of virus in your body) down.


HIV experts cite several reasons for going on ARVs as soon as you learn you’re HIV positive:

• ARVs lower your viral load, making it unlikely that you’ll pass HIV to someone else.
• It’s preferable to start HIV treatment before the virus has a chance to further damage your immune system.
• Starting ARVs early appears to reduce the risk of diseases associated with aging, such as cardiovascular disease, that aren’t related to AIDS but seem to be more common in people with HIV than in people who don’t have the virus.

 Yet, there’s no one-size-fits-all approach to treating HIV. The decision about when to start treatment and what to take is yours alone to make. It depends on your physical health and your mental readiness to start treatment and stick with it. There are potential drawbacks to starting treatment immediately:

• Starting treatment right away gives you less time to prepare yourself for staying on it and adhering to your meds as prescribed.
• The longer you take ARVs, the greater your risk of developing side effects, including long-term ones that may not yet be identified.
• Your risk of developing resistance to HIV drugs increases with long-term use.

That’s why your doctor shouldn’t simply hand you a prescription and say, “Here, take this,” Agosto says. “There are many factors that have to be considered.”


For example, he says, when people who are aging find out they’re positive, they have to do a more thorough inventory of their health, as certain medications may interact with other medications they may be taking. Fortunately, these days you and your doctor have a variety of ARVs from which to choose.


Besides your physiology, socioeconomic factors—such as your income, whether you have insurance and what kind of support you have from family and friends—play a role in determining the likelihood of your going on HIV treatment and staying on it.


Your circumstances shouldn’t prevent you from getting tested and starting treatment, though, Agosto says. “I think the major obstacles are the ones people create in their heads,” he says. Some people may think they cannot afford treatment. And some people still regard an HIV diagnosis as a death sentence, which, in their mind, makes treatment pointless.


Unfortunately, young people and people of color are more likely to put off getting tested, and if they’re positive, they’re more likely to put off starting medication until they get sick, Agosto says. “They find out when they have a bout of pneumocystis pneumonia.”


The need to go on treatment is especially urgent in people who’ve been diagnosed with AIDS and in HIV-positive pregnant women. If you’re diagnosed with HIV while pregnant, you need to consider starting ARVs right away. They not only will protect your health but will also prevent you from passing HIV to your baby. 

If you were taking ARVs before you got pregnant, you should keep taking them.


Once you start HIV treatment, you have to take your medication every day, exactly as prescribed, for the rest of your life. That may seem challenging, but it’s no different from what people with other chronic diseases, such as high blood pressure or diabetes, must do in order to stay as healthy as possible. Plus, in some cases, you may be able to take your full HIV drug regimen as a single combination pill, which makes sticking with treatment even easier.


You’ll also need to have regular checkups in order to monitor your CD4 count and viral load to ensure that the HIV drugs are working properly. Be sure to discuss any problems you may have with your doctor. If you find that you are missing doses or experiencing side effects, you may be able to switch your current regimen for one that is easier to take.


“If you’re informed, if you do your research, if you go to the community and look for resources, you will be fine,” Agosto says.


Consider This

When choosing an HIV regimen, discuss these questions with your health care provider:

Potency: Is the regimen powerful enough to fight my virus and keep my viral load undetectable?

Safety: What kind of short- and long-term side effects will the meds have on my overall health?

Convenience: How many pills must I take, and how many times a day?

Interactions: How does the regimen work with other medications (including over-the-counter drugs) and supplements I am taking?

  

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