Below is information about an article being published early online on July 20 at www.annals.org. This article will be published in the Aug. 4 print edition of Annals of Internal Medicine. The information is not intended to substitute for the article as a source of information. Annals of Internal Medicine attribution is required for all coverage.
International clinical trials are currently underway to assess when is the best time to initiate antiretroviral therapy (ART) in HIV-infected patients. However, results will not be available for several years. Medical experts recognize that treatment outcomes are better when HIV-infected patients are started on ART before their CD4 (cells that help initiate the body's response to invading viruses) count gets too low. But how low is the question. A typical healthy adult has a CD4 count between 600 and 1,200. The fewer CD4 cells a patient has, the greater the risk for opportunistic infection. This risk is particularly great in resource-limited settings. While awaiting international study results, researchers sought to determine the optimal CD4 threshold at which to initiate ART in South Africa. The investigators used a computer-simulation model of HIV disease to perform a cost-effectiveness analysis of three treatment options: no treatment, ART initiated at a CD4 count less than 250, and ART initiated at a CD4 count less than 350. Compared with a threshold of 250, starting therapy at 350 was highly cost-effective. The researchers conclude that early therapy at a higher CD4 threshold will probably reduce morbidity and mortality, improve long-term survival, and be cost-effective for patients in South Africa. While awaiting trial results, current guidelines should be liberalized to allow initiation of treatment at the higher threshold.