This just in:
WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms.
Which makes eminent sense, of course. Because if starting HIV therapy might prolong survival in developed countries, why shouldn’t it do the same in the developing world?
In fact, when you consider the higher incidence of TB and invasive bacterial infections in such settings, it could easily be argued — and has been argued — that starting early would net greater survival gains in resource-poor settings than it would here.
Plus, there’s the CIPRAHT001 Study, which proves it.
But there’s more — the new WHO guidelines also urge that countries “phase out” the use of stavudine in favor of less-toxic NRTIs, and that women continue breastfeeding so long as they are also on ART.
Good news all around.
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FROM NEJM — Recent Infectious Disease Articles
Should the guidelines have suggested initiation at < 500 as is expected in the next iteration of US centered guidelines? Although ARVs are limited in many parts of the world should an individual patient be witheld therapy when there is an accumulation of data suggesting 500 (or higher) may be the tipping point? A conundrum in areas where supplies of ARVs are limited perhaps.
CM,
I guess one way of looking at “start at CD4 350” is “start at CD4 > 350.” I realize it’s not exactly the same thing, but since you can’t predict when or if the CD4 will drop, as a pt approaches this threshold (i.e., between 350 and 500), it’s time to get ready to start.
As you know, DHHS guidelines just out as well.
Paul