"HIV is a shark", according to Italy's Stefano Vella, one of three senior researchers offering a treatment primer on Monday morning. "Shoot early, but not too early. Remember that you only have one shot – two if you're quick. And aim well."

With these words of warning, Vella outlined the current consensus on when to begin antiretroviral therapy, although he cautioned that "no controlled trials tell us exactly when to start."

He suggested beginning treatment early for patients at "risk for progression", including those with CD4 counts that drop below 500 or who have viral loads of more than 10,000 copies. He said achieving viral suppression of below 50 copies is essential to achieving long-term success. Doug Richman, who spoke later on resistance issues, concurred, saying "the lower one goes, and the faster one gets there, the more likely you are to remain there."

As many other sessions will outline at this Conference, the risks associated with beginning triple therapy as recommended include adherence difficulties, the limitation of future treatment options, and unknown long-term toxicities. In particular, the difficulty of adhering to complicated regimens remains a problem. Vella sent a message to other physicians that "we need to support and improve adherence rather than just making note of it."

He also offered data about the use of triple therapy in children, noting that trial data indicated "immune reconstitution in children was very, very quick." On this basis, he called for better access to drug treatment for children.

Patrick Yeni from Paris concluded the session with the latest data on maintenance and salvage therapies. Citing both a US and a French trial, Yeni explained that efforts to simplify treatment regimes have not been successful. Dubbed "induction-maintenance therapies," these trials tried hitting hard with triple therapy, then pulling back to one or two drugs.

The trials "were stopped due to [unacceptable] failure rates," Yeni said. While this "doesn't mean that the concept of treatment simplification is not valid," he suggested that maximum but simplified dosing regimens may be a better route of investigation.

this story can also be found in The Bridge, the onsite print newspaper

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