There are now 13 anti-HIV drugs available by prescription. Combinations of anti-HIV drugs are now commonly called HAART, which stands for Highly Active Antiretroviral Therapy. HAART combinations usually include three or four anti-HIV drugs. Studies have shown that HAART can work well in people with an AIDS diagnosis or symptoms of HIV infection. However, for people earlier in their disease who don't have symptoms of HIV or AIDS, the best time to begin HAART is not certain.

One thing is quite clear: you don't necessarily need to take HIV drugs just because you're HIV positive. HIV causes illness by damaging the immune system. Measuring the T4 cell count gives an idea of how the immune system is doing, and can also help decide if anti-HIV drugs are needed. The other important test is called the viral load test. The viral load test measures the amount of HIV in a blood sample.

Measuring both the T4 cell count and the viral load can help work out if you're at risk for disease progression over the next few years. In one large study, for example, a person who started with T4 cells between 350 and 500 and a viral load of less than 14,000 copies had a very low risk of disease progression over the next three years. Their risk of progressing to a diagnosis of AIDS within three years was about 5%, or a 1 in 20 chance. For people in this position, waiting a while to plan a treatment strategy is not likely to put your health at risk.

A person who started the same study with a T4 cell count in the same range (350-500) but a viral load of over 110,000 had a much greater risk of disease progression. Their risk of progressing to a diagnosis of AIDS within three years was close to 50%, or a 1 in 2 chance. Most doctors would strongly recommend treatment if you're in this situation.

If you're risk of disease progression is low, waiting to start treatment can be a good strategy for a number of reasons: * You may benefit from new information about which combinations of HIV drugs work best, and have the fewest side effects. This can help you plan a HAART combination that you can stick with.

* By regular monitoring of your T4 cell count and viral load, you can get a better idea of how your immune system is doing against HIV.

* You may be in a better position to benefit from new drugs that are not yet available.

* You can avoid the side effects of currently available anti-HIV drugs, which may have a bad effect on your quality of life - in other words, the drugs may make you feel sick even though HIV isn't making you feel sick yet.

One argument against waiting to start treatment is that HIV may be causing ongoing immune system damage. However, it's clear from research studies that serious illnesses are rare when a person's T4 cell count is over 200. To be on the safe side, most doctors would recommend HIV treatment before the T4 cell count drops below 350 cells.

Notes on Viral Load Testing The first time you get your viral load tested, most doctors recommend doing two tests, about a week apart. That way, you get a better sense of viral load levels because you have two separate test results to compare. Viral load tests can occasionally go wrong, and doing two tests avoids the possibility of making treatment decision based on incorrect results.

Public Health Service guidelines recommend monitoring viral load every 3-4 months if you're not yet taking HIV treatments. Changes in viral load and T4 cell counts over time can help work out if you're risk of disease progression is increasing.

Viral load tests aren't perfect. The test gives a rough estimate of the amount of virus in a blood sample. Results can change, even if you do two viral load tests on the same blood sample. This problem is called "variability." The variability of the viral load test can be approximately three-fold. This means that a test result of 15,000 copies could come back anywhere between 5,000 (three-fold less than 15,000) and 45,000 (three-fold more than 15,000). Because of this variability, small changes in viral load test results - e.g. from 10,000 to 15,000 - don't necessarily mean that the viral load has changed.

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