An old and controversial issue has re-emerged as a leading HIV treatment story—when to start therapy. There are not now, nor have there ever been, clear cut, black and white rules for the majority of people living with HIV. Sure, if your CD4 counts are very low (200 or less) and you have a high viral load (greater than 10,000) most “experts” agree you should start highly active anti-retroviral therapy (HAART). But what if your viral load is 10,000 and your CD4 count is 450? This is a less clear picture among the “experts”.

As we (patients, doctors, and researchers) have gained experience with HAART the once clear picture of “hit hard, hit early” is much less clear. The rush to put every HIV positive person on HAART that many healthcare providers joined may not have been a good course. Clearly, for many people who had low CD4 counts and high viral loads, HAART has been a life saver. But for many people who had few signs of immune system damage and who felt good, HAART has proven to be a bad deal. Many of these people have suffered side effects that lower their quality of life while providing no proven benefit.

While there are many gray areas, there are a few points where most “experts” agree. If you have a high CD4 count (greater than 500) and a relatively low viral load (less than 10,000) you are not a high priority candidate for starting HAART. If you have a low CD4 (200) and a viral load over 10,000 you should very seriously consider HAART. If you do choose to go on therapy, it should be one of the multi-drug “cocktails” (HAART), not a one or two drug therapy. Once you decide to start therapy you must understand the importance of, and be committed to, taking the medicines on time, every day. Finally, whether you choose to be on HAART or not, you should continue to see a healthcare provider regularly (at least every four months) to monitor your CD4 count, viral load, and other important signs. Just because you choose not to be on HAART does not mean you should not monitor your health.

HIV therapy remains as much an art as it is a science. Every month brings new insight into how and when to treat. As I have said many times before, choosing a treatment is your option. Your healthcare provider can offer their “expert” opinion. We can provide you with “facts,” guidelines and personal experiences. But ultimately the decision to go on therapy is yours.