We review the current literature supporting adoption of higher CD4 thresholds for initiation of antiretroviral treatment and survey progress in adoption of early treatment policies in resource-limited settings. We highlight some of the challenges and opportunities implementation of early treatment will bring.
The initial success of combination antiretroviral treatment resulted in the recommendation to treat early all individuals with HIV. However, the gradual realization that antiretroviral treatment was associated with toxicity led to a more tempered approach. Recent cohort studies and some clinical trials have shown that delaying treatment is associated with increased morbidity and mortality.
Early treatment is routinely practiced in developed countries. Now, early treatment is being adopted as a strategy in many resource-limited settings. The implications of this policy shift are not known, but we predict early treatment will have important consequences for the health system, the individual, and the community. Whereas these consequences will bring significant challenges, the increased numbers of HIV-infected individuals on treatment will result in many new opportunities – antiretroviral treatment will become less expensive, systems to deliver chronic care will be strengthened, and the policy shift will focus greater attention on pregnant women and children. Finally, some authors postulate that early treatment may impact HIV transmission.
aDepartment of Pediatrics, Division of Infectious Disease and Immunology, NYU School of Medicine, New York, New York, USA
bClinton Foundation HIV/AIDS Initiative, Boston, Massachusetts, USA
Correspondence to Dr Shaffiq M. Essajee, BMBCh, MA, Department of Pediatrics, NYU School of Medicine, NBV 8W51, 550 First Avenue, New York, NY 10016, USA Tel: +1 212 263 1534; fax: +1 212 263 7806; e-mail: firstname.lastname@example.org