The 'When to Start ART' Debate

Abstact and Introduction

Introduction

Patients starting antiretroviral therapy in Africa had a much better chance of survival if their on-treatment CD4 count reached >500 cells/mm³.

In developed countries, HIV-positive patients on antiretroviral therapy (ART) who survive the first 6 months of treatment may have a life expectancy similar to that of their HIV-negative peers, particularly if their CD4 counts rise above 500 cells/mm³ during treatment. However, in resource-constrained settings, limited data are available on long-term mortality in patients receiving ART.

To address this issue, researchers reviewed data from 27,018 patients in Africa who had been receiving initial ART free of charge for at least 9 months (median pre-ART CD4 count, 152 cells/mm³; 68% women). During a median follow-up of 3.3 years, 2.4% of patients died and 10.3% were lost to follow-up.

Overall mortality rates declined substantially with longer durations of ART: 1.03 deaths per 100 person-years during the second year of ART, 0.93 during the third year, and 0.64 during the fourth. In a multivariate analysis, higher CD4-cell counts during treatment were associated with lower mortality rates: The odds of survival were significantly better among patients with CD4 counts >500 cells/mm³ than among those with CD4 counts between 350 and 500 cells/mm³ (adjusted hazard ratio, 1.7) or between 200 and 349 cells/mm³ (aHR, 2.6). In a sensitivity analysis in which patients who were lost to follow-up were considered dead, these associations were attenuated but remained significant.