Box 1.

Indications for antiretroviral therapy in adults with HIV infection.

We recommend initiation of lifelong ART for all patients diagnosed with HIV infection. The CD4 count and clinical stage of the patient should no longer be a consideration in the decision to start ART.

For patients who are asymptomatic with CD4 > 350 cells/μL, additional time (weeks to a few months) can be spent counselling and preparing the patient for lifelong ART with good adherence before starting. In those with CD4 < 350 cells/μL (and especially < 200 cells/μL), or with clinical indication for starting, there should not be undue delay.

Within ART programmes, it is important to factor in that the absolute benefit of ART is much greater at lower CD4 counts (there is a mortality benefit at CD4 < 350 cells/μL.10† Therefore, planners and clinicians should prioritise and fast-track those with low CD4 counts (especially < 200 cells/μL); this is particularly relevant where there are ART shortages or anticipated stock-outs.

^†Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. 2010;363:257–265. PMID: 20647201, http://dx.doi.org/10.1056/NEJMoa0910370