When should HAART (Highly Active Antiretroviral Therapy) not be initiated in patients with AIDS (Acquired Immune Deficiency Syndrome)?

When Not to Start HAART in AIDS

HAART should not be initiated in patients with AIDS who have active central nervous system (CNS) opportunistic infections such as cryptococcal meningitis or tuberculosis meningitis, as early initiation has been shown to increase mortality in these specific conditions. 1

Contraindications to Immediate HAART Initiation

CNS Opportunistic Infections

• Early initiation of HAART in patients with cryptococcal meningitis has been shown to increase mortality, particularly in resource-limited settings 1
• Similarly, patients with tuberculosis meningitis may experience worse outcomes with early HAART initiation, as demonstrated in a study from Vietnam 1
• In these cases, HAART should be deferred until the CNS infection is adequately treated and stabilized 1

Patient Readiness Considerations

• HAART should be delayed in patients who are not ready or able to adhere to therapy, as poor adherence can lead to resistance development 1
• Patients who refuse to take HAART despite counseling should not be forced to start therapy 2, 3
• Psychological readiness and ability to commit to lifelong therapy should be assessed before initiating HAART 1

Timing of HAART in Special Circumstances

Acute Opportunistic Infections (Non-CNS)

• For most non-CNS opportunistic infections, early HAART (within 2 weeks of OI treatment) is beneficial and reduces mortality 1
• The ACTG A5164 trial demonstrated a 50% reduction in AIDS progression or death with early HAART during treatment of acute OIs 1
• However, timing should be individualized based on the specific infection and patient's clinical status 1

Tuberculosis Co-infection

• For patients with active tuberculosis (non-CNS), HAART should generally be initiated, especially in those with CD4 counts <50 cells/μL 1
• Three randomized trials have demonstrated that early ART led to important clinical benefits in TB patients with advanced immunosuppression 1
• However, TB meningitis remains an exception where early HAART may not be beneficial 1

Clinical Scenarios Where HAART May Be Temporarily Deferred

Severe Acute Illnesses

• In patients with severe, acute systemic illnesses where immediate HAART might complicate management (e.g., severe sepsis), temporary deferral may be appropriate 1
• Once the acute condition stabilizes, HAART should be initiated promptly, especially in patients with CD4 counts <200 cells/μL 1

Drug Interactions and Toxicities

• When significant drug interactions between HAART and treatments for acute OIs cannot be managed safely, HAART initiation may need to be delayed 1
• This is particularly relevant for patients receiving treatment for tuberculosis or fungal infections with complex drug interactions 1

Monitoring Considerations During HAART Deferral

• For patients in whom HAART is deferred, close monitoring of CD4 counts and viral load is essential 1
• Prophylaxis against opportunistic infections should be initiated according to CD4 count thresholds while awaiting HAART 1
• For patients with CD4 counts <200 cells/μL, Pneumocystis pneumonia prophylaxis is strongly recommended during the period of HAART deferral 1

Current Recommendations vs. Historical Context

• Current guidelines have evolved significantly from earlier recommendations that suggested deferring HAART until CD4 counts fell below 200 cells/μL 1
• The 2002 WHO guidelines endorsed treatment initiation only in patients with WHO Stage IV disease or CD4 counts <200 cells/μL 1
• Modern guidelines now recommend HAART for all HIV-infected individuals regardless of CD4 count, with few exceptions as noted above 1

Common Pitfalls in HAART Decision-Making

• Unnecessarily delaying HAART in patients without clear contraindications can lead to disease progression and increased mortality 1
• Failing to recognize CNS opportunistic infections as exceptions to early HAART initiation 1
• Not providing appropriate prophylaxis against opportunistic infections during necessary HAART deferral 1
• Overlooking the importance of patient readiness and potential adherence issues before initiating therapy 1