Dear doctor,

I am in agreement with you.

Moreover, you can read these documents:

Penazzato M, et al., Cochrane Database Syst Rev. 2012

Lawn SD, et al., Curr Opin Infect Dis. 2011

Perno CF. Ann Ist Super Sanita. 2011

Here's a recent article related to your question:

The Lancet. Volume 376, Issue 9738, 31 July–6 August 2010, Pages 340–345

Death rates in HIV-positive antiretroviral-naive patients with CD4 count greater than 350 cells per μL in Europe and North America: a pooled cohort observational study.

http://www.sciencedirect.com/science/article/pii/S0140673610609324

Would suggest you do a Pubmed search. There have been various literature on the topic and a number of reviews and position papers have already been published.

That said, you need to weigh the benefits of starting ART early against the risk of adverse events and lifetime cost of starting treatment early (among other things). Another argument for starting ART early is in treatment-as-prevention scenarios.

Accordingly to the latter International AIDS Society (IAS) recommendations during the Conference held in Washington this year, ART should be offered to all HIV-patients regardless to their CD4 T-cell counts...

You can find further info reading the papers referred by Edward and Salvatore.

In my view the earlier one starts ART the better it is for the patient. In San Francisco (see the work of Diane Havlir) they now recommend starting ART as soon as possible for the benefit of the individual patient. The attached file shows that even at the highest CD4 cell counts mortality is significantly higher in those infected with HIV.

This should have been attached to previous answer.

Dear all,

This question is on the priority research agenda of WHO for the management of HIV-TB co-infection in resource constrained settings. Since the person who raised this question is from the same resource constrained setting as I am from, the answer to it should be tailored accordingly.

Yes, many developed countries have moved ahead with a higher cut off of CD4 (500) and there are yet others which are considering "test & treat".

But most countries are yet to catch up with this due to obvious reasons. The only way that this can be taken up by all countries is if someone does a cost benefit analysis. One of the greatest benefit in such countries where TB is rampant, is that it reduces spending on TB control.

San Francisco has a policy of recommending ART as soon as the patient is diagnosed, and it's working well so far.

http://www.hivandhepatitis.com/hiv-aids/hiv-aids-topics/hiv-treatment/3532-croi-san-francisco-early-treatment-policy-linked-to-lower-viral-load-higher-cd4-count

Well, I dont think the US Govt. will have second thoughts over such a policy. Thanks for the link Howard. What about the medicines? Does the US Govt supply them free of cost or is it dependent on the individual patients pockets?

For reduce mortality in patients with opportunistic infections have shown several benefits

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0005575

This is other interesting example

http://cid.oxfordjournals.org/content/50/11/1532.full.pdf+html

A few promiscuous homosexual friends of mine have mentioned that HAART initiation within one day of exposure to HIV will effectively cure an exposed individual. While this is purely anecdotal and these friends are not scientists, I would consider that HIV infection is of considerable concern in the gay community, so there may be validity to this, although I can't say for certain without a more thorough literature review. Theoretically, stopping HIV reproduction while few cells are infected could give the immune system a chance to kill off the infected cells before they release viable virions, especially if the HAART is administered for long enough a period of time. This would necessitate, however, knowing one has been infected with the virus, such as a known positive HIV status of a sexual partner and known transmission of HIV-containing bodily fluids (or a needlestick with known HIV-positive blood on the needle). Just getting some at-risk populations to get tested for HIV can be a challenge, so this method of cure would be rather rare. Try looking up case reports about it.

THERE IS AN EFFECTIVE RESULT IS SHOWN ON A COMPARITIVE STUDY FOR THE ERALY INITIATION OF THE TREATMENT IN HIV PATIENTS BEFORE CD4 COUNT FALL..The results of this study suggest that among patients with a 351-to-500 CD4+ count, the deferral of antiretroviral therapy was associated with an increase in the risk of death of 69%, as compared with the early initiation of therapy. Among patients with a more-than-500 CD4+ count, deferred therapy was associated with an increase in the risk of death of 94%. As has been shown in previous studies, an older age was an independent risk factor for death,5,50 as were a history of injection-drug use35 and the presence of HCV infection.

This question has been raised several times during the decades of ART and recommendations changed several times and in both directions: start earlier and start later.

The main reasons to start earlier were always ideas in the direction to avoid the development of AIDS or opportunistic infections and assumptions in a way to see better long-term outcome (which could never be shown) or to induce better immune control of the virus (which could be shown but not for the majority of patients).

The main reasons to start later were side effects of ART mainly induced by PIs (lipodsytrophic disorder) or by NRTIs (lipoatrophy and other symptoms of mitochondrial inhibition) and the lack of show a long-term benefit to start earlier. In contrast it was been shown that a later start leads to the same CD4 cell count after immune reconstitution in most cases than as if started earlier.

One could argue now that more recently approved antiretrovirals have less side effects (or less known long-term side effects) or that no benefit ever could be shown to start early.

In order not to argue in a modern way instead of a rational way (irrespective of who is arguing) because this happened already to often in the short history of ART, I would recommend ART for everyone only, as soon as it is possible to receive non-toxic antiretrovirals for everyone and for each individual life-span long (also adjustable to drug resistance occurencies in each country). In other words, as soon as we can assure that an individual starting ART will not have a worse outcome due to drug resistance development or due to treatment toxicity combined with no option to change the regimen.

Early initiation of ART. in HIV and AIDS.

Who is eligible, for start of ART, when does one start ART and why. What are the benefits of starting early ART. Just the fact that one has HIV infection does not indicate that one should be under treatment. In HIV infection there are slow and fast multipliers of HIV viruses that lead to fast or slow evolution of the disease.

assuming that a child has got HIV or a new born has HIV infection ART is initiated early.

Level of CD4 is another indicator for deciding on the start of ART.

Assume that all HIV infected people had ART. then the transmission rates decrease but the resistance of the drug increases leading to more mutant forms of HIV. The only answer to HIV is to make the body capable of eliminating HIV and to administer a suitable vaccine.

Stop HIV AND AIDS.

ART is secondary.

Interesting point of view, Satyaprasad Venkata, and I can see promising progress in terms of cure. We are all aware that there is a lot of scientific research in order to learn how to cure and how to vaccinate against HIV infection, and I appreciate it.

But there is no elimination and no vaccine to administer yet, and as far as I can see, there will be probably none, at least not within the next ten years (maybe the same ten years we were talking about already for the last 30 years for HIV vaccination).

So it may be allowed, only as long as this is the case and only in order to avoid people dying, to discuss how to apply functional drugs best, ... and primarily.

Thank You Dr Walter, When i was in the ART center as a medical officer i treated many HIV patients and initiated ART early, some against protocols, and was aggressive in pushing the drug to the needy. But it was unfortunate that the higherups had an one sided eye and failed to see the benefits but was concerned about statistics. I have seen the benefits of starting ART early and also the risk of ART.

In India which is known as a fertile ground for HIV, and tuberculosis which is gaining importance the more frequent detection of MDRTB have probably been linked to HIV.

MY point is will ART alone suffice to improve CD4 hence resistance then health, then less chances of TB and more chances of not having MDRTB

Several studies by Stephen Lawn and colleagues in South Africa have suggested that incidence of TB and mortality following ART initiation to be directly correlated with CD4 counts. For example

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0034156

Thank you Dr. Venkata, too. My comment was not to mention you were not right and I agree there is an urgent need for cure and vaccination, in particular because there is ART failure and consequent disease progress.

I assume, that no, ART cannot sufficiently improve alone the immune recovery, in particular not in world-wide settings. Unfortunately, there is no option yet.

And altogether, this underlines even more the need to discuss the best way when and how to administer ART. But I would agree, if you will say that initiation criteria of ART could be adjusted to the possibilities and realities to offer ART in different settings.

As Akshay , I think that antiretroviral therapy should be started as soon as possible (before Tcell decreases a lot) .Because earlier ART may lead to better outcomes.

You might like to look at this paper also...

An interesting correspondance-debate up to date on New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMc1210464

You can read several opinions on antiretroviral preexposure prophylaxis for HIV prevention, that are interweaved with the question of ART initiation.

Once a person living with HIV begins medication therapy he/she must be committed to taking medication for the rest of their lives. Starting therapy early might not be the best choice for some individuals. Adherence to treatment is essential to prevent resistance. If a patient does not adhere to their medication or cannot maintain access to health care and/or medications we would not see improved outcomes.

"A new study" published in the New England Journal of Medicine, shows the advantage of beginning antiretroviral therapy within four months of infection with HIV, the virus that causes AIDS." Investigators "analyzed data from nearly 500 patients infected with HIV-1 and found that those who began antiretroviral therapy within four months of their infection date -- and had higher CD4+ T-cell counts at the start of therapy -- had a stronger recovery of key CD4+ T-cell counts than those who began treatment later." The investigators reported that ..normal CD4+ T-cell counts were restored in 64 percent of patients who began antiretroviral therapy within four months of infection, compared with 34 percent of patients who began treatment later.

Yes: http://www.medpagetoday.com/HIVAIDS/HIVAIDS/36869?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&xid=NL_DHE_2013-01-17&eun=g344460d0r&userid=344460&email=hrincon@hotmail.com&mu_id=5338243

Does the initiation of Prep beneficial to serodiscordant couples? comments

Here you can find an excelente apprisal of recent letrature.

http://www.hivandhepatitis.com/hiv-aids/hiv-aids-topics/hiv-treatment/3951-very-early-hiv-treatment-may-delay-disease-progression-raise-cd4-count

Some background information.

In 2000 the International AIDS Society (IAS) and the American Department of Health and Human Services (DHHS) guidelines recommended starting treatment if an HIV-positive person had a CD4+ count less than 350/μL (IAS) or 500/μL (DHHS) or a viral load greater than 5k/mL (IAS1) or 10k/mL (DHHS2). Both were based on data from the MACS cohort. Applying these guidelines would have ensured that all those with a greater than about 5% chance of developing AIDS in the next three years would be started on ART. In South Africa in that year 90% of the people then living with HIV would have started treatment immediately.

In 2002 the WHO guidelines recommended starting treatment at a CD4+ cut-off of 200/μL with no viral-load criterion. In South Africa 10% of the people then living with HIV would have started treatment immediately. In their 2002 guidelines WHO noted that ‘While beginning therapy before the CD4 cell count falls below 200/μL clearly provides clinical benefits, the actual point above 200/μL at which to start therapy has not been definitively determined.’

The Department of Health and Human Services in the United States now supports immediate treatment for all HIV-positive people.

hello, this question has many answers. but many questions too need to be answered.

defining a patient requring the start of art is based on age, sex pregnancy, tuberculosis, oppertunistic infections, and the last but not least drug resistance.

when these are answered the patient may be started on ART

Definitely will benefit if patient is properly evaluated before initiation of HAART. evaluation for other bacterial (Mycobacterium tuberculosis), viral (Hepatitis B, Hepatitis C Viruses) and fungal (Histoplasma capsulatum, Peumocystis jirovecii and Cryptococcosis) and other hematological conditions (Anaemia). Satyaprasad Venkata was right patients age etc., have also play the role. HAART has many side effects so physicians must weigh benefits over toxic effects of HAART and take an appropriate decision in each patient

The most important point is CD4 count, most patient with CD4 count higher than 350 cells/μL are benefit from ARV Tx.The other important points are mentioned about by Satyapyasad Venkata , especially those with Hepatitis B co-infection,HIV associated renal disease.

Studies have shown mortality benefit with regardless of CD4 count (NEJM 360:1815,2009)