TREMENDOUS ADVANCES in the development of effective antiretroviral therapy
for human immunodeficiency virus 1 (HIV-1) infection have been associated
with an ongoing debate regarding when to initiate antiretroviral therapy.1,2 Although the concept of delayed therapy
is somewhat foreign to the field of infectious diseases, it has been supported
by concerns about the long-term benefits of therapies currently available,
the rigors of the currently available regimens, and the typically slow course
of disease in persons with HIV-1 infection. Advances in treatment have been
paralleled by recent advances in the understanding of HIV-1 pathogenesis,
which provide important new insights as to how the virus is affected by immune
selection pressure and why antiviral drug resistance is so prevalent. In our
opinion, currently available data provide convincing arguments for initiation
of therapy at the earliest possible juncture in persons who are not controlling
viremia on their own.
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