7.1.1 When to start ART in adults and adolescents
Consolidated ARV guidelines, June 2013
Rationale and supporting evidence: Potential harms and feasibility
Not all observational studies have consistently demonstrated the beneficial impact of initiating ART earlier on mortality and the incidence of non-AIDS events associated with chronic inflammation and ongoing viral replication, and longer follow-up is needed to evaluate potential harms and benefits. The long-term safety profile of ART and the implications of earlier initiation on drug resistance and toxicity will also need to be closely monitored.
According to cohort and national programme data, the number of people needing treatment could increase by up to 25% if eligibility is based on CD4 counts increasing from ≤350 cells/mm3 to ≤500 cells/mm3 (47,48) (Web Annex). However, country experience has also shown that moving to a higher CD4 threshold for ART initiation may not necessarily lead to a significant immediate increase in the numbers of people who actually access treatment in the absence of increased uptake of HIV testing and counselling, stronger linkages to care, adequate treatment monitoring and sustained adherence support.
Implementing the recommendation to initiate ART in individuals with HIV with CD4 counts between 350 and 500 cells/mm3 may involve additional human, infrastructure and financial resources. Chapter 10 discusses these issues in further detail.