Rapid antiretroviral therapy initiation in low- and middle-income countries: A resource-based approach

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 (Table Significant attention has been focused on rapidly initiating ART, reflected in the 2017 WHO guidelines, 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/L) 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.