July 23, 2009
A new study finds that starting treatment when CD4 cells drop below 350 per cubic millimeter of blood could save 76,000 lives in South Africa alone over the next five years. Mathematical modeling also showed that starting South African patients on treatment sooner could prevent around 66,000 cases of HIV-related diseases like TB during the same time period.
The World Health Organization recommends starting HIV treatment when CD4 levels drop below 200, to delay the costs and side effects associated with the drugs. However, developed nations such as the United States recommend initiating treatment when CD4 levels drop below 350, and two studies published this year found patients who begin the drugs when their CD4 cells drop below 500 have higher survival rates.
The new study, led by Rochelle Walensky of Harvard Medical School and funded by the National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation, compared the likely effect of three scenarios: beginning treatment when CD4 cells fall below 250, when they drop below 350, or when no treatment is given. Assuming South Africa's current infection rates continue and 30 percent of those infected are diagnosed, 76,000 lives would be saved within five years if treatment was initiated at the higher level, the scientists said. The extra costs are reasonable relative to South Africa's gross domestic product per capita, they added.
Given the projections, health authorities should switch to earlier treatment now, rather than wait for the results of trials now underway in South Africa. "Waiting five years for trial results could be more costly in human terms," Walensky and colleagues said. "Decisions must be made now."
In a speech Monday at the International AIDS Society conference in Cape Town, Julio Montaner, the group's president, said raising the threshold to 350 for developing world HIV/AIDS patients would be "more appropriate and clinically sound."
The study, "When to Start Antiretroviral Therapy in Resource-Limited Settings," was published ahead of print in the Annals of Internal Medicine (2009;151(3)).
07.20.2009; Simeon Bennett