Deciding to start ART requires weighing the benefits of treatment on morbidity and mortality against its risks, including toxicity, resistance, drug interactions, and the costs and inconvenience of lifelong treatment. Sustained viral suppression restores and preserves immunologic function, decreasing opportunistic diseases and mortality. The patient must be ready and willing to adhere to lifelong therapy. Advances in ART continue to shift the therapeutic risk-benefit balance to earlier treatment. Improvements in potency, toxicity and tolerability, and pill burden allow for durable viral suppression for most patients. The risks associated with ART have decreased, whereas concerns regarding the risks of long-standing untreated viremia have increased. Uncontrolled HIV replication and immune activation lead to a chronic inflammatory state, resulting in end-organ damage and co-morbid conditions not previously thought to be associated with HIV infection. Several studies have shown that the life span of those with HIV infection still falls short of that of the general population, even at high CD4 cell counts. 3-6 This life span decrease is related to serious, non-AIDS events attributed to chronic immune activation and the potentially permanent immune damage associated with prolonged immune depletion. In several data sets, 3-8 non-AIDS events were associated with elevated levels of viral replication and markers of immune activation and coagulation (including D-dimer, interleukin 6, or high-sensitivity C-reactive protein). Mortality from non-AIDS events now exceeds that of AIDS-defining opportunistic diseases in individuals receiving
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