With the risks of HIV antiretroviral therapy (ART) decreasing and concerns regarding untreated disease on the rise, an international panel has updated its guidelines on when to start treatment (JAMA. 2010;304:321-333).

In its recommendations, the panel acknowledges that the decision to initiate ART requires weighing the morbidity- and mortality-related benefits of treatment against the risks of therapy: toxicity, resistance, drug interactions, and the cost and inconvenience of lifelong treatment. They also assert that patient readiness for treatment is a key consideration in the decision to begin ART. Yet as far as clinical factors are concerned, “There is no CD4 cell count threshold at which initiating therapy is contraindicated,” according to the panel.

Specifically, ART should be initiated:

  • In symptomatic persons with established disease, regardless of CD4 cell count
  • In asymptomatic persons with CD4 cell counts <500/µL
  • In all HIV-positive persons who exhibit a rapid decline in CD4 cell count (>100/µL) or a plasma HIV-1 RNA level >100,000 copies/mL; who are aged 60 years or older; who are pregnant; who have certain coinfections or comorbidities as specified in the panel’s report (JAMA. 2010;304:321-333); or who have symptomatic primary HIV infection.

Finally, consider ART for asymptomatic individuals with CD4 cell counts >500/µL.

In related news, early initiation of ART reduced the rates of death and incident tuberculosis in a trial of 816 Haitian adults (NEJM. 2010;363:257-265), and the annual number of new HIV diagnoses in Canada has fallen by more than half since the introduction of highly active ART in 1996 (Lancet. 2010;376:532-539). In the U.S., the Office of National AIDS Policy issued the National HIV/AIDS Strategy.