Earlier initiation of antiretroviral therapy should be highest priority for expansion of HIV care, study finds

"Immediate scale-up of the entire WHO guideline package may be prohibitively expensive in some settings," said lead author Rochelle P. Walensky, MD, MPH of the Massachusetts General Hospital, Boston. "In many resource-limited settings, the relevant policy question is: What to do first?"

The new WHO guidelines include three major changes: initiation of ART when CD4 levels drop below 350/µl, rather than waiting until they reach 200/µl; replacing the antiretroviral drug stavudine with the less-toxic but more expensive tenofovir for first-line treatment, and switching patients to second-line ART regimens when the first-line regimen fails.

Findings from Walensky and colleagues demonstrate that earlier ART initiation increased 5-year survival from 80 to 87% and showed substantially improved early clinical outcomes compared to either using tenofovir for first-line treatment or providing second-line regimens. In settings where ART initiation at 350/μl is already available, switching stavudine to tenofovir offers clinical benefit and is less costly than adding second-line regimens. Finally, the authors demonstrate that the availability of second-line regimens offers major survival benefits (greater than 4 years per person) but at substantial increases in cost.

The authors conclude: "The entire package of recommendations proposed by the WHO is cost-effective in South Africa (incremental cost-effectiveness ratio of US$2,370 per year of life saved). However, in settings where immediate implementation of all of the new WHO treatment guidelines is not currently feasible, antiretroviral treatment initiation at CD4 < 350/µl provides the greatest short- and long-term survival advantage and is highly cost-effective."

Rochelle Walensky is an Associate Professor of Medicine at Harvard Medical School. Additional co-authors of the PLoS Medicine report are Andrea L. Ciaranello MD, MPH, Sarah B. Lorenzana, Adam W. Stoler and Kenneth A. Freedberg, MD, MSc, MGH Department of Medicine; Robin Wood, FCP, MMed, DTM&H, Desmond Tutu HIV Centre, University of Cape Town; A. David Paltiel, PhD, Yale School of Medicine; and Xavier Anglaret, MD, PhD, INSERM Unité 897, Centre de Recherche "Epidémiologie et Biostatistique." The study was supported by grants from the NIAID, NIDA, and the Doris Duke Charitable Foundation.