Should patients with an acute opportunistic infection receive antiretroviral therapy immediately?

The treatment of patients who have the human immunodeficiency virus (HIV) and opportunistic infections (OIs) presents a number of challenges; optimal treatment strategies for these patients are not well defined. At present, there is little agreement as to whether these patients should begin antiretroviral therapy (ART) immediately, or whether ART should be deferred until the OI has resolved. Combination treatment regimens required to treat HIV and OIs simultaneously are associated with several complications, including increased risk of gastrointestinal toxicity, drug-related anemia, lack of adherence to treatment, and drug interactions. HIV-associated OIs are increasingly common among disadvantaged patient populations, who are at high risk of hepatitis C infection, substance abuse, and lifestyle factors that further complicate treatment. In addition, many patients exhibit an inflammatory immune response following treatment for certain OIs or the initiation of ART. However, it has also been shown that high-potency ART regimens that rapidly reduce the HIV viral load and improve CD4 cell counts significantly reduce the risk of subsequent OIs. A randomized, controlled clinical trial has been designed to compare treatment outcomes associated with immediate versus delayed initiation of ART in patients with OIs.