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The Benefits of Treatment upon Diagnosis

Dr. Vivek Jain reviews research on early initiation of antiretroviral treatment and HIV-related inflammation. One challenge that has confronted the medical community since the beginning of the HIV epidemic lies in determining when to start patients on antiretroviral therapy. The initial approach favored delaying treatment until substantial benefit was evident, in the interests of avoiding medicine-related toxicities and viral resistance. However, medicines have become less toxic, and there is new evidence that early initiation of ART can limit the amount of inflammation, immune dysfunction, and related negative health impacts. T-cell activation, meaning exterior presence of CD38 and HLA-DR molecules on T-cells, is associated with rapid immune system decline, poor recovery, cardiovascular disease, and higher death rate. HIV as a chronic disease results in dysfunction of the immune system, scaring of lymph nodes, and susceptibility to other infections, and ART may result in treatment toxicity, lipid alternations, and kidney and liver toxicity. These combine into geriatric syndromes such as coronary artery disease and cancer. Dr. Jain addresses the question: What role can early ART play in optimizing HIV as a chronic condition? He presents evidence that shows how early initiation ART can limit the severity of some of these conditions. For instance, early ART prevents stiffening of vascular arteries and neurologic inflammation. It can limit the size and scope of the viral reservoir. That raises the question of whether ultra-early therapy along with adjunct interventions can prevent creation of the viral reservoir. Issues involving toxicity and durability of regimens remain, but a promising array of adjunct therapies is being studied.