The most appropriate next step in management is to defer initiation of antiretroviral therapy (ART) or other HIV-associated treatment pending further discussion of this patient's diagnosis and its management. Although ART initiation is recommended in all patients regardless of CD4 cell count and there are public health benefits to early treatment to reduce transmission of infection, this patient raises several concerns for possible poor adherence to therapy and the likelihood of suboptimal treatment. Adherence to HIV treatment may be influenced by numerous factors, including behavioral (denial, nondisclosure of HIV status, fear of stigma), psychosocial (mental illness or low levels of social support), and structural (poverty, homelessness, inconsistent access to medications) barriers; low health literacy; active substance use; and age (young adults have increased difficulty with adherence). It is important for patients with any of these risk factors to discuss their disease and the goals of therapy to optimize the chance for adequate adherence to treatment. Therefore, the most prudent strategy is to take additional time for counseling and education to prepare this patient for success in adhering to ART and other HIV treatments. Because his CD4 cell count is still high and viral load is low, his risk for rapid progression of disease is low, allowing additional time to accomplish this.

The patient's CD4 cell count is not less than 200/µL and is unlikely to decrease that low in the near future considering his high CD4 cell count now and low level of viral activity. Therefore, providing Pneumocystis jirovecii prophylaxis with trimethoprim-sulfamethoxazole before initiating ART is unnecessary.

Because of the concerns for adherence with this patient, initiation of any ART is best delayed until the chances for medication adherence are improved. Once that is accomplished, however, it would be inappropriate to wait for an arbitrary CD4 count to begin therapy. There are benefits to initiating ART early, in terms of both improving the patient's health and reducing potential transmission to others.