When Should I Start Treatment?
When Should I Start Treatment for HIV?
Starting treatment is always an individual decision. It is important to discuss all the benefits and risks to starting treatment, and your personal readiness to start treatment with your doctor. It is recommended that people living with HIV begin treatment as soon as possible.
Australian Society for HIV Medicine (ASHM) is the peak body that sets out the Clinical Treatment Guidelines for Australia. As new evidence and new treatments arise, the guidelines are amended to reflect the Australian context. The clinical guidelines can be complex so we have produced the following brief summaries and support guides below.
Recommended Guidelines for all PLHIV
Current guidelines recommend treatment for all PLHIV regardless of CD4 count.
- Current research is encouraging PLHIV to begin treatment as soon as possible. It suggests that the sooner treatment is started, the better.
- The evidence for people with CD4 counts above 500 beginning treatment is strong.
- Results for two large randomised controlled trials (START and TEMPRANO) were published in 2015, both demonstrated that the clinical benefits of antiretroviral therapy (ART) are greater when ART is started early, with pre-treatment CD4 counts >500 cells, rather than when initiated at a lower CD4 cell count.
- This offers important evidence regarding the optimal time to start treatment, to reduce the risk of disease progression and the inflammatory effects of HIV on the body.
Recommended Rapid Treatment Start Guidelines
Guidelines recommend more rapid start to treatment, in the following situations:
- Opportunistic Infections or AIDS-defining illness (including dementia).
- Rapidly declining CD4 count (e.g. above >100 CD4 cell loss over a year)
- Very low CD4 counts below < 200.
- HIV associated kidney disease (called “HIVAN”).
- Hepatitis B or Hepatitis C coinfection.
- Acute/Recent HIV diagnosis (within the last 6 months).
- High Viral Load >100,000 copies.
HIV treatment can also be used successfully for the prevention of HIV. Read more through the links below.
What treatments should I start with?
The Australian Treatment Guidelines follow US Department of Health & Human Services (DHHS) which currently recommend several drug combinations as the recommended treatment to start with. They are mostly either 1 or 2 pills, taken once a day. Your doctor will discuss the recommended choices with you, but if you are unsure about making a decision, or which combination to choose, please seek more information.
You can also check out this visual list of all the current HIV antiretroviral (ARV) treatments available in Australia. This guide also includes information about the HIV life cycle and how HIV medications work in the body.
Guidelines for Antiretroviral (ARV) Regimen for a Treatment-Naive Patient
An antiretroviral (ARV) regimen for a treatment-naive patient generally consists of two nucleoside reverse transcriptase inhibitors (NRTIs) administered in combination with a third active ARV drug from one of three drug classes: an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor (PI) with a pharmacokinetic (PK) enhancer (also known as a booster; the two drugs used for this purpose are cobicistat and ritonavir).
- Data also support the use of the two-drug regimen, dolutegravir plus lamivudine, for initial treatment.
- Before initiating antiretroviral therapy (ART) in a person of childbearing potential, a pregnancy test should be performed (AIII). Before prescribing ART to a person of childbearing potential, please refer to Table 6b for information about safety of different INSTI-based regimens taken around the time of conception.
- The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) classifies the following regimens as Recommended Initial Regimens for Most People with HIV (in alphabetical order):
- Bictegravir/tenofovir alafenamide/emtricitabine (AI)
- Dolutegravir/abacavir/lamivudine—only for individuals who are HLA-B*5701 negative and without chronic hepatitis B virus (HBV) coinfection (AI)
- Dolutegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide or tenofovir disoproxil fumarate)a (AI)
- Dolutegravir/lamivudine (AI)—except for individuals with HIV RNA >500,000 copies/mL, HBV co-infection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available.
- Raltegravir plus (emtricitabine or lamivudine) plus (tenofovir alafenamide [TAF] or tenofovir disoproxil fumarate [TDF])a (BI for TDF, BII for TAF)
Guidelines for Recommended Initial Regimens for Most People with HIV
Selection of a regimen should be individualized based on virologic efficacy, potential adverse effects, childbearing potential and use of effective contraception, pill burden, dosing frequency, drug-drug interaction potential, comorbid conditions, cost, access, and resistance test results. Drug classes and regimens within each class are arranged first by evidence rating, and, when ratings are equal, in alphabetical order.
INSTI plus 2 NRTIs:
For individuals of childbearing potential, see Considerations Before Initiating Dolutegravir and Other Intergrase Strand Transfer Inhibitors as Initial Therapy for Persons of Childbearing Potential
before prescribing one of these regimens.
INSTI plus 1 NRTI:
- BIC/TAF/FTC (AI)
- DTG/ABC/3TC (AI)—if HLA-B*5701 negative
- DTG plus (TAF or TDF)a plus (FTC or 3TC) (AI)
- RAL plus (TAF or TDF)a plus (FTC or 3TC) (BI for TDF/[FTC or 3TC], BII for TAF/FTC)
- DTG/3TC (AI), except for individuals with HIV RNA >500,000 copies/mL, HBV coinfection, or in whom ART is to be started before the results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available
In addition to the above regimens, alternative/other regimens are available which may be the preferred regimen for some patients, due to unique clinical and personal needs. The preferred regimens (above) are usually offered because they are the easiest to take and tolerate, are less complicated, and have the greatest and strongest evidence for first-line use. Please click here to see a full, clinical list of treatment regimens on ASHM’s website. On this page, you will find several tables describing the recommended treatment regimens for individuals with different circumstances.
The selection of a treatment regimen should be individualised on the basis of efficacy, toxicity (side effects), number of pills, dosing frequency, drug interactions (with any other treatments), resistance test results, and other health conditions you might have. These can all affect the decisions about which treatments to take.
Your complete individual clinical and personal circumstances are important considerations in order to make a joint decision with your doctor about what treatment will be best for you.
How Much Does Treatment Cost?
Treatment for HIV is available throughout Australia at highly subsidised costs for Medicare Card holders, through the PBS.
Where Can I Get Treatment?
People living with HIV can get their HIV medication from their local pharmacy, an online pharmacy or a hospital-based pharmacy, whatever suits them better.
Accessing Treatment Without Medicare
It is possible for anyone in Australia to access HIV treatment without medicare, in many cases for free.
Drug Resistance & Adherence
HIV drug resistance is caused by changes in the genetic structure of HIV that affect the ability of medicines to work effectively. Ensuring you are as consistent with your regime as possible reduces this possibility.
Side Effects & Changing Treatment
Modern HIV drugs tend to have minimal side-effects but some side effects can still occur. This is why all changes to your treatment should always be in consultation with your HIV doctor.
Our trained team is here to help you should you have any questions or need support. You can call for free from a Queensland land-line on 1800 636 241 or call (07) 3013 5555 (national). You can also email us or use the contact form or the chat function in the corner of our website.