When should someone start Antiretroviral Treatment (ART)?

Starting ART sooner, and not waiting to be sick or have symptoms, is better. South Africa has a Universal Test and Treat (UTT) Policy, which means that anyone who tests positive for HIV can start taking ART immediately, no matter what their CD4 count is.

It is important not to skip or stop taking ARVs. Skipping or stopping can lead to drug resistance. Once someone starts taking ARVs, they must take them every day at the same time. It is a lifelong commitment.

If a person is not sure whether they can stick to taking their ARVs, then it may be better to wait until they feel they are prepared and can stick to treatment. A person living with HIV can find out what their regimen will be. Use sweets in a practice run to get used to the routine. Find a family member or friend who can be a treatment buddy to provide support.

If viral load is high - more than 1000 - and their CD4 count is low -200 or less - it is important to start treatment as soon as possible.

Don't wait until your CD4 count is very low!

What to expect at the clinic

Blood tests

A Viral Load (VL) test is a blood test done every 6 months.This measures how much virus there is in a drop of blood.

  • Results are given as copies of the virus per millilitre of blood (copies/mL).
  • If there are less than 50 copies of the virus in one millilitre of blood, this will not show up in the blood test. The test results will come back saying the virus is 'undetectable'. This is viral load suppression.
  • The aim of ART is viral load suppression but this can only happen if with adherence to ART. It does not mean that someone is cured but that there is a small amount of the virus in their body.

After starting ART your viral load is the most important measure of how well the body is responding to treatment and whether viral suppression has been achieved. This is the most important test to judge whether or not ART is working.
A CD4 count is a blood test done once a year:. This test measures how many immune cells there are in a very small amount (cells per cubic millimetre, cells/mm3) of blood:

  • Thisblood test measures how many CD4 cells are in the blood.
  • The higher the CD4 count is the stronger the immune system is.
  • A result of about 500-1,500 is considered normal.
  • Every time the CD4 count drops by 100, the relative risk of acquiring AIDS doubles.

Before starting ART the CD4 count is the best indicator of how healthy the immune system is. It will tell your doctor how urgently you need to start to start treatment.

Other tests which will be run at the clinic include tests to monitor liver function, blood sugar and cholesterol.

First-line ART Regimens

There are many different kinds of ARVs and that means there are different treatment regimens. When someone starts ART, the healthcare worker will discuss which regimen is best for that person.

Treatment regimens for all people initiating ART, 15 years and older

Regimens for all people testing positive for HIV including:

  • Pregnant & breastfeeding women
  • People with Hepatitis B
  • People with TB

Tenofovir (TDF) + Emtricitabine (FTC) + Efavirenz (EFV)
*Usually given as 3 ARVs in 1 pill taken once a day (FDC)*


Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV)

If Efavirenz is not right for someone it will be replaced with Nevirapine.

Tenofovir (TDF) + Lamivudine (3TC) + Nevirapine (NVP)

If Efavirenz and Nevirapine are not right for someone, they will be replaced with Lopinavir/Ritonavir:

Tenofovir (TDF) + Emtricitabine (FTC) + Lopinavir/Ritonavir (LPV/r)


Tenofovir (TDF) + Lamivudine (3TC) + Lopinavir/Ritonavir (LPV/r)

If Tenofovir is not right for someone, it will be replaced with Abacavir:

Abacavir (ABC) + Lamivudine (3TC) + Efavirenz (EFV)


Abacavir (ABC) + Lamivudine (3TC) + Nevirapine (NVP)

Side effects and ART

Don't let side effects stop you from starting ART! Many people are scared to take ARVs because they have heard bad stories about their side effects. When someone first starts ART they may have side effects, but not everybody does. Two people taking the same drug may have different side effects.

Side effects usually only last a week or two while your body is getting used to the ARVs. Even if side effects are experienced, it is important not to skip or stop taking the ARVs. It is best to speak to a healthcare worker about steps that can be taken and medication that can help manage side effects. Sometimes the healthcare worker will swap an ARV in the treatment regimen for a different one that the body handles better.

Short-term side effects can include:

  • Tiredness
  • Nausea (wanting to vomit)
  • Vomiting
  • No appetite
  • Diarrhea (running stomach)
  • Headache
  • Fever
  • Muscle pain
  • Dizziness 
  • Insomnia (sleeplessness)
  • Change in body shape

Click here for more information on side effects.