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Starting and Monitoring ART

Advances in HIV treatment over the past several decades have made HIV a manageable, chronic condition. Antiretroviral therapy (ART) is used across the globe to suppress the virus, improve overall health, and prevent future transmission.

ART is a combination of medicines taken every day. Although it does not cure the virus, it does make it possible for individuals living with HIV to lead much longer lives.1-4 Some research suggests that taking ART every day as prescribed can increase an HIV-positive individual’s life expectancy to roughly that of someone who does not have the virus.5

When should I start ART?

Current clinical guidelines indicate that ART should be started as soon as possible after an individual is diagnosed with HIV. Some clinics may even start treatment the same day as diagnosis.3,4,6,7 In the past, some guidelines suggested waiting until an individual’s CD4 count fell below a certain level. CD4 cells are immune cells, also called T-cells, that get infected and destroyed by HIV, leading to life-threatening complications. However, after reviewing several studies and consulting experts in HIV care, the guidelines have been changed to starting HIV as soon as possible, regardless of time since diagnosis, the clinical symptoms or conditions an individual has, or their CD4 count.8-11

HIV research in recent years has shown that the earlier treatment with ART is started, the better an individual’s overall health outcomes, ability to suppress the virus, and long-term CD4 counts will be. Starting ART as soon as possible and successfully suppressing the virus can also decrease the risk of further HIV transmission.8-11

The only exception to this is for individuals who currently have an emotional, physical, or psychosocial barrier that prevents them from taking their medication as prescribed. HIV has the ability to mutate and become resistant to some of the medications used to treat it. In order to suppress the virus, have adequate levels of medication in the body, and prevent the virus from mutating, ART needs to be taken exactly as prescribed, every day. If an individual will not be able to take their medication as directed, further support may be needed, such as counseling, drug rehabilitation programs, or other interventions to assess and overcome immediate obstacles and help set them up on the road to success with treatment.4

It’s important to remember that taking ART is very important, even if you don’t “feel” sick. HIV progresses in three phases, early-stage or acute HIV infection, chronic HIV infection or clinical latency, and late-stage HIV infection or AIDS (acquired immunodeficiency syndrome). The longest stage of HIV infection is the middle stage, clinical latency. During this time, an individual may have no symptoms of the virus at all, but it is still slowly destroying their immune system. The virus is also able to be transmitted during clinical latency. Taking ART at all times, including when no symptoms are present, is still important in preventing the virus from impacting your immune system and having better overall health outcomes.

How will I know if my ART is working?

Your healthcare provider will monitor you while you’re taking ART to make sure the medication is working and to watch for any treatment failures. Whenever a new ART regimen is started or significantly changed, your provider will check your CD4 count and your HIV viral load (a measure of how much HIV is in your blood). They may also do drug resistance testing to make sure your HIV will respond to the medications chosen, and again if treatment isn’t adequately controlling your HIV. Your CD4 count and viral load will continue to be monitored at various points throughout treatment to make sure that the medication is still doing its job, and that the virus hasn’t gotten worse.2-4,6

The goal of treatment is to get an individual’s viral load as low as possible. If treatment is successful, an individual’s viral load will be so low, they will be deemed “undetectable”. This means there is not enough virus in their blood sample to be picked up by lab testing. When an individual has an undetectable viral load, their risk of transmitting the virus to others is essentially zero (referred to U=U, undetectable = untransmissible), and their overall health outcomes are better.12 A low viral load allows the body to build its CD4 count up, which also helps improve overall health.

A person is thought to be responding to treatment if they have a viral load of less than 200 copies of the virus per milliliter of their blood within 24 weeks of starting treatment. If they do not reach this point after 24 weeks, or if they have a viral load of greater than 200 copies per milliliter for a sustained period of time after they’ve previously been suppressed, it may be time to try a new medication regimen.2 Your healthcare provider will monitor your laboratory tests closely to determine how well you’re responding and if new treatment is needed. The best way to prevent a treatment from failing is to take it as directed every day. This keeps the virus suppressed in your body and prevents it from mutating. When the virus mutates, it can gain resistance against a drug and the drug becomes less effective.

Other laboratory tests that your provider may order before or during treatment to understand your overall health include, but are not limited to:

  • Hepatitis screening
  • Tuberculosis (TB) testing
  • Testing for other sexually transmitted infections (including chlamydia, gonorrhea, and syphilis, among others)
  • Liver function tests
  • Kidney function tests
  • Complete blood counts (CBC)
  • Glucose levels (blood sugar testing)
  • Urine analysis
  • Pregnancy testing (for persons of reproductive age who are sexually active)
  • Pap smear2,3,6

Your provider will let you know what tests they’re ordering and why. If you are not sure why you’re getting a specific test done, or think you should be getting a certain test, check-in with your healthcare team.

Written by: Casey Hribar | Last reviewed: September 2019
  1. Starting Antiretroviral Treatment for HIV. Avert: Global Information and Education on HIV and AIDS. https://www.avert.org/living-with-hiv/starting-treatment. Published December 14, 2017. Accessed June 30, 2019.
  2. Sax PE. Patient Monitoring During HIV Antiretroviral Therapy. UpToDate. https://www.uptodate.com/contents/patient-monitoring-during-hiv-antiretroviral-therapy. Published May 7, 2018. Accessed June 30, 2019.
  3. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. U.S. Department of Health and Human Services: AIDSInfo. https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf. Published October 25, 2018. Accessed June 30, 2019.
  4. Initiation of Antiretroviral Therapy. U.S. Department of Health and Human Services: AIDSInfo. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/10/initiation-of-antiretroviral-therapy. Published October 17, 2017. Accessed June 30, 2019.
  5. Teeraananchai S, Kerr SJ, Amin J, Ruxrungtham K, Law MG. Life expectancy of HIV-positive people after starting combination antiretroviral therapy: A meta-analysis. HIV Med. Apr 2017; 18(4), 256-266.
  6. Goldschmidt RH, Chu C, Dong BJ. Initial management of patients with HIV infection. American Family Physician. 1 Nov 2016; 94(9), 708-716. Available from: https://www.aafp.org/afp/2016/1101/p708.html. Accessed June 30, 2019.
  7. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/186275/9789241509565_eng.pdf;jsessionid=A48349DA6E4102E54585C95B7C1B5EAC?sequence=1. Published September 2015. Accessed June 30, 2019.
  8. INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 2015; 373(9), 795-807. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26192873. Accessed June 30, 2019.
  9. Samji H, Cescon A, Hogg RS, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PloS one. 18 Dec 2013; 8(12), e81355. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24367482. Accessed June 30, 2019.
  10. Moore RD, Keruly JC. CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression. Clin Infect Dis. 2007;44(3):441-446. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17205456. Accessed June 30, 2019.
  11. Palella FJJ, Armon C, Chmiel JS, et al. CD4 cell count at initiation of ART, long-term likelihood of achieving CD4 >750 cells/mm3 and mortality risk. The Journal of antimicrobial chemotherapy. Sep 2016; 71(9), 2654-2662. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27330061. Accessed June 30, 2019.
  12. Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: Undetectable equals untransmittable. JAMA. 5 Feb 2019; 321(5), 451-452.