A practical resource-based public health approach for the rapid initiation of antiretroviral therapy in HIV-infected individuals living in low- and middle-income countries could save thousands of lives, according to an Essay published in the open-access journal PLOS Medicine by Mark Tenforde of the University of Washington School of Medicine, and colleagues.

Antiretroviral therapy (ART) has substantially decreased HIV morbidity and mortality in high-income as well as low- and middle-income countries (LMICs). Several randomized trials have demonstrated benefits from starting ART regardless of CD4 count; the World Health Organization (WHO) adopted a “treat all” strategy.

ART be initiated within 7 days of HIV diagnosis

Significant attention has been focused on rapidly initiating ART which recommend that ART be initiated within 7 days of HIV diagnosis and on the same day whenever possible. Although considerable progress has been made, a significant proportion of patients starting ART in LMICs continue to present with severe immunosuppression, with recent laboratory-based surveillance showing that one-third of South African patients still enter care with advanced HIV infection (CD4 < 200 cells/μL).

These late presenters have the highest risk for death, unmasking of opportunistic infections (OIs), and immune reconstitution inflammatory syndrome. The guidelines highlight these patients and state that “people with advanced HIV disease should be given priority for clinical assessment and treatment initiation”.

Paradoxically, difficulties in implementing guidance on screening for OIs may result in the greatest delays in ART initiation in this population who are at the most risk. According to Tenforde and colleagues, current strategies are inadequate for identifying and preventing opportunistic infections and related deaths in late presenters. The authors present a resource-based approach according to diagnostic test availability for targeting opportunistic infections in the "treat all" era.

The approach could decrease early mortality after antiretroviral therapy initiation and would be practical to implement. Even the most resource-constrained settings can implement interventions that have the potential to save thousands of lives, while further refinement can be offered in settings where rapid screening for common opportunistic infections is feasible.

According to the authors, an optimal approach requires that pre-antiretroviral therapy CD4 testing continues to be available (preferably as a simple point-of-care threshold test), although viral load testing has been supplanting CD4 testing in high-burden countries in the "treat all" era. "We believe this provides a pragmatic algorithm to avoid delaying antiretroviral therapy for the most immunosuppressed patients who are at the highest risk of dying," the authors write.