Art of initiation of antiretroviral therapy (in ARV naive patients).

T first cases of HIV infection were reported in 1981 and today, more than 30 years later: there are approximately 34 million people currently living with HIV and nearly 30 million people have died of AIDS-related causes since the beginning of the epidemic.1 The prevalence of the disease varies greatly across nations, with the highest disease burden in sub-Saharan Africa. South and South-east Asia, including India, account for an estimated 4 million individuals living with HIV in 2011.1 The number of persons living with HIV in India in 2008-2009 was estimated to be 2.4 million, with significant variation in prevalence across states.2 There is wide spectrum of opportunistic infections/ events occur during natural history of HIV infection, tuberculosis continues to be the commonest infection, others: oral / esophageal candidiasis, infective diarrhea / secretary diarrhea, herpes zoster, pneumocystis jiroveci pneumonia (PCP), neuro-toxoplamosis, cryptococcal meningitis, pruritic papular eruptions, seborrhoic dermatitis, reactivation of herpes simplex virus (HSV) and others. Many people present late with advanced HIV infection viz absolute CD4 count less than 350 and / or with AIDS defining illness at the time of HIV diagnosis3. One of the major causes of death inspite of initiation antiretroviral therapy is late presentation. Late presenters : mostly symptomatic, fairly sick with multiple opportunistic infections / events, higher mortality rate, high chances of immuno-reconstitution inflammatory syndrome (IRIS) and antiretroviral therapy must be initiated Combination ART, first introduced in 1996, has led to dramatic reductions in morbidity and mortality, and access has increased in recent years, rising from less than half a million people on treatment in 2003 to 8 million people in 2011, a 63% increase in the number of people on treatment since 2009. More than half (54%) of the 14.8 million people who were eligible for treatment were receiving it in 2011.7,8 There are people living with HIV (PLWH) who are eligible for anti-retroviral therapy (ART) and almost sixty percent have access to ART (Figure 1). It is needless to mention that ART has significant effect in reducing morbidity and mortality amongst PLWH, also there is reduction in incidence of new infection. The goals of ART are;9 1. Virological goal; viral load reduction < 40 copies as long as possible. 2. Immunological goal; Immune reconstitution ; elevation of CD4 count 3. Clinical goal; reduction in morbidity and mortality, increase in life span, improvement in quality of life. 4. Theraputic goal: Sequencing of drugs to achieve clinical, virological and immunological goals. Editorial