When to start HIV treatment? It seems there’s no consensus and, as far as most of Canada is concerned, no guidelines either. It used to be - and often still is - that starting treatment was recommended only when our CD4 cell counts had fallen to a certain level — 200, or 350 or 500. Yet those numbers keep changing and vary between jurisdictions. The Americans have tended to be more aggressive about recommending treatment at higher CD4 numbers, while the Europeans have, for the most part, been more conservative. In the absence of national guidelines (Québec and British Columbia have provincial ones), Canada has tended to follow the U.S. lead.
The arguments against early treatment are familiar and are nicely summarized in this recent CATIE article. Yet many guidelines, including the American ones, increasingly call for starting treatment shortly after diagnosis, regardless of CD4 cell count. This is because many experts believe that starting treatment early has many positive long-term health outcomes.
To address some of the complexities of this issue, I asked Colin Kovacs, an HIV primary care physician in Toronto, when he thought was the best time for someone living with HIV to start treatment. I caught up with him on the sidelines of last fall’s research conference of the Ontario HIV Treatment Network and you can watch our conversation in the video below.