Purpose of review: When should people with HIV start treatment? This question is widely debated. The recent momentum to initiate treatment at a CD4 cell count above 350 cells/mm3 is driven by the potential population benefits of antiretroviral treatment reducing infectiousness together with operational concerns. These are important. However, we focus on the clinical benefits and risks for the person taking treatment, and how this may vary depending on the background health setting.
Recent findings: We refer to the recent guideline changes and the limited evidence on which they are based. Many studies that have informed guideline changes reference plausible benefits, but have limited follow-up and are not designed to assess the potential risks. We note historical examples to show that expert opinion in the absence of data warrants caution.
Summary: Results from well powered studies designed to look at the question of when to start treatment are essential for quantifying the benefits and risks of earlier treatment. Meanwhile, the decision of when to start must be taken by the HIV-positive person in consultation with their health worker based on accurate information. That choice will vary depending on a person's individual health, their reason to want to treat and the resources of the health-care facility.