Before people start antiretroviral therapy (ART), health-care providers should initiate a detailed discussion about the willingness and readiness of patients to initiate ART, the antiretroviral (ARV) drug regimen, dosage, scheduling, likely benefits, possible adverse effects and the required follow-up and monitoring visits. In the case of children with HIV, this conversation should directly involve the caregiver and include discussion about disclosing their HIV status. Retesting all people living with HIV before initiating ART is recommended to ensure a correct diagnosis of HIV infection. Initiation of ART should always consider nutritional status, any comorbidities and other medications being taken to assess for possible interactions, contraindications and dose adjustment.
The choice to accept or decline ART ultimately lies with the person or his or her caregiver, and if they choose to defer initiation, ART can be offered again at subsequent visits. If the person faces mental health or substance use issues or other potential barriers to ART initiation or adherence, appropriate support should be provided and readiness to initiate ART should be reassessed at regular intervals. Community and peer support can help a person to prepare and make the decision to start therapy.
People starting treatment and carergivers should be informed that the first ART regimen offers the best opportunity for effective viral suppression, immune recovery and consequently clinical benefit and that successful ART requires all medications to be taken as prescribed. It is important to acknowledge that there are situations where delays in starting ART can have negative consequences, particularly for people with tuberculosis (TB) or advanced immunosuppression, who are at high risk of death. People should be advised that many adverse effects are temporary or may be treated, and that substitutions can often be made for the ARV drugs associated with adverse effects. In preparation for treatment initiation, it is important to assess the need for psychosocial support to optimize adherence. People receiving ART and caregivers should also be asked regularly about any other medications that are being taken, including herbal remedies and nutritional supplements.
People commencing ART should be given advice on safer sex, including condom use and avoidance of other high-risk activities such as sharing of injecting equipment, to prevent transmitting HIV to other people.