Firstly, before starting treatment someone has to be ready to do so. All treatment guidelines state that someone needs to be prepared to take treatment before they start.

Secondly, anyone with any HIV-related symptoms is usually recommended to start treatment (at any CD4 count).

Thirdly, everyone—with or without symptoms—is recommended to start before their CD4 count falls to below 200 cells/mm³.

Most countries now recommend starting before the count falls to 350 cells/mm³. Some guidelines recommend starting below 500 or have no CD4 upper limit.

Current research is looking at risks and benefits of starting at higher CD4 counts. Several studies show no benefit from starting at 500 compared to 350. Some guidelines include reasons why starting earlier may have benefits. Currently the international START trial is looking at this in a large randomised study.

Being ready to start treatment involves understanding that:

• Treatment will help your health.
• The best adherence means taking every dose and this is linked to the best chance of treatment success.
• Adherence means following any food recommendations.
• Side effects will usually be mild and can be managed.

These ‘non-medical’ aspects are very important:

• Someone has to be committed to treatment before they start.
• If adherence is not good, resistance will develop and treatment will fail.

See Section 1 — Use of CD4 count to start treatment