Box 10.2 Key implementation considerations for programme managers: raising the CD4 threshold for initiating ART in adults and adolescents from 350 to 500 cells/mm3

Consolidated ARV guidelines, June 2013

  • Treat the sickest people first. Individuals with CD4 cell counts of less than 350 cells/mm3 have a different mortality profile than those with higher CD4 cell counts. What systems will be in place to ensure that the sickest people are adequately given priority, especially in settings with low ART coverage?
  • Phase out d4T. Given the long-term toxicity and side effects of d4T, programmes raising the ART initiation threshold to 500 CD4 cells/mm3 should have significantly progressed in phasing out d4T in adult and adolescent regimens to optimize treatment outcomes.
  • Consider task shifting and decentralization. Human resource plans should be developed or adjusted to support the policy decision to increase the CD4 eligibility threshold, including through task shifting and training new cadres of health workers (see section 9.5.2).
  • Reinforce adherence support. A higher threshold for initiating ART means that more people who feel healthy will become eligible for treatment. What interventions to promote and reinforce adherence will be implemented for these people?
  • Provide treatment monitoring. As more people initiate ART earlier and stay on it for longer, monitoring viral suppression becomes increasingly important, as keeping people on failing regimens may lead to higher levels of drug resistance, which might compromise the efficacy of treatment, especially of NNRTIs. How will access to viral load monitoring be scaled up?