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BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3257 (Published 12 August 2009) Cite this as: BMJ 2009;339:b3257

Africans with HIV should start taking antiretrovirals earlier

The World Health Organization recommends that people with HIV start antiretroviral treatment when they reach stage 3 or 4 of the disease or when the CD4 count decreases to fewer than 200 × 106 cells/l. However, starting treatment earlier may reduce the rates of opportunistic infections, prolong life, and be cost effective. Modelling studies done in developed countries have found that starting treatment when the CD4 count drops below 350 × 106 cells/l, or even below 500 × 106 cells/l, may be beneficial. A study now confirms that this may be true for South Africa too.

A computer simulation model that used data from randomised trials and observational cohorts in South Africa estimated that if treatment was started when the CD4 count is 350 × 106 cells/l rather than when the CD4 count is 250 × 106 cells/l then over the next five years 25 000 deaths could be saved if 10% of people infected with HIV are identified and linked to care. If all HIV positive people were identified, 253 000 deaths would be averted. The incremental cost effectiveness ratio was estimated to be $1100 (£660; €770) per year of life saved for starting treatment at 250 × 106 cells/l compared with no treatment, and $1200 for starting treatment at 350 × 106 cells/l compared with 250 × 106 cells/l.

Trials are under way to determine the optimal time to start antiretroviral treatment in people with HIV, but the results will not be available for five to 10 years. Until then, argue the authors, treatment guidelines should be liberalised to allow antiretroviral treatment to start at a CD4 count of <350 × 106 cells/l; they say, however, that this should only be implemented in settings with adequate capacity to treat …

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