7.1.1 When to start ART in adults and adolescents

Consolidated ARV guidelines, June 2013

Rationale and supporting evidence: Cost and cost–effectiveness

The Guidelines Development Group reviewed mathematical simulations of the costs and epidemiological benefits of initiating ART at a CD4 count ≤350 cells/mm3, CD4 count ≤500 cells/mm3 and for all adults with HIV regardless of CD4 cell count. These models suggest that expanding the ART eligibility criteria to ≤500 cells/mm3 could lead to substantial health benefits and be cost-effective in both generalized and concentrated epidemic settings; the increased cost of earlier ART would be partly offset by subsequent reduced costs (such as decreased hospitalization and increased productivity) and preventing new HIV infections (Web Annex).

However, these benefits depend on a high testing uptake, high treatment coverage, sustained adherence and high rates of retention in care. The models also show that, because the greatest costs are associated with full implementation of the 2010 ART guidelines (2) (initiating ART at CD4 count ≤350 cells/mm3), the incremental cost of moving the ART initiation criterion from a CD4 count ≤350 cells/mm3 to ≤500 cells/ mm3 is relatively small, especially if countries already have a substantial number of people with HIV with a CD4 cell count less than 350 cells/mm3 already receiving ART.

These modelling findings support the recommendation to initiate ART in adults and adolescents with HIV with a CD4 count ≤350 cells/mm3 as a priority. However, the cost implications at the regional and country levels should be explored further, since countries have different levels of treatment coverage and local cost considerations depending on their context and resources.