The HIV treatment pendulum. (Guest Editorial).

In HIV disease, the pendulum has recently swung toward delaying initiation of antiretroviral therapy. I would like to highlight potential pitfalls of this new approach and, perhaps, push the pendulum the other way.

Perhaps we should not prevent patients from starting therapy early They may be right.

After years of discussion about initiating HIV therapy I would argue that we still have no definitive consensus on when we should start therapy. Treatment guidelines addressing this question have been driven by some data and much opinion.

Some people see this question as pointless, arguing that HIV-infected people typically come into the hospital with low T-cell counts and thus need to start therapy.

But that's a bit of an exaggeration. Each year 20,000 people become infected in the United States, and some choose to defer therapy. So the issue of when to initiate HIV therapy is very relevant in practice.

Just a few years ago, clinicians followed a hit-hard, hit-early approach and treated all patients.

Now there's a much more conservative approach, and we're treating patients later, primarily because of concerns about the risk of serious toxicity from long-term antiretroviral therapy.