The "When to Start ART" Debate

Comment

Numerous studies have demonstrated that the probability of on-treatment CD4 counts reaching >500 cells/mm³ depends on the pre-ART CD4-cell count. Thus, this study adds to the growing body of data on the potential benefits of starting ART at levels higher than that presently recommended by the WHO (<350 cells/mm³). However, earlier treatment is not without its challenges, including the need for long-term adherence and the possibility that serious, unforeseen toxicities could emerge after decades of continuous ART. Additionally, the excess mortality risk associated with untreated HIV infection may be small at CD4 counts >500 cells/mm³, which may limit the cost-effectiveness of ART initiation above this level. The final balance of these pros and cons of starting ART at higher CD4-cell counts is likely to be settled only in randomized clinical trials. Until then, the debate continues.

AIDS Clinical Care © 2012 Massachusetts Medical Society