The "When to Start ART" Debate

More Data in Favor of Earlier Treatment

Mauro Schechter, MD, PhD


AIDS Clinical Care 

In This Article

Abstact and 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.