Primary HIV infection: to treat or not to treat?

Purpose of review The aim of this article is to review new data on the use of antiretroviral therapy in primary HIV infection. Recent findings The concept of 'hit HIV hard and early' supporting the use of antiretroviral therapy to treat the early stages of HIV infection has been revisited. Recent demonstration of massive, rapid and largely irreversible HIV-mediated destruction of memory CD4+ T cells predominantly occurring in the gut suggests that primary HIV infection may be the only time that intervention could confer lasting immunological benefit. There are no data, however, from randomized controlled trials supporting the use of antiretroviral therapy in primary HIV infection, although a number of observational studies have demonstrated limited, transient improvements in measured immunological outcomes. The first randomized controlled trials powered to address whether antiretroviral therapy of a limited duration in primary HIV infection can influence long-term CD4 decline (SPARTAC) is now fully recruited but will report in 2-3 years. In addition, given that individuals with primary HIV infection contribute disproportionately towards onward HIV transmission, there may be an additional public health impetus for earlier diagnosis and intervention in primary HIV infection. Summary In the absence of randomized controlled trials data demonstrating clinical benefit of antiretroviral therapy intervention in primary HIV infection, clinical guidelines remain unclear. Intervention seems a logical strategy to counter the high viraemia, enhanced onward transmissibility, and immunological destruction which occurs during primary HIV infection. The nature, duration and timing of that intervention after HIV acquisition remains unknown.