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.