When to start antiretroviral therapy in adults in low-income and middle-income countries: science and practice

Purpose of review To review data related to the outcomes of antiretroviral therapy (ART) and the current operational experiences of ART programmes in low-income and middle-income countries (LMICs), concentrating on the implications and feasibility of changing ART initiation practice. Recent findings ART initiation practice inhigh-income country settings has been modified in favour of starting ART earlier, basing on early evidence that HIV-associated morbidity and mortality are significantly reduced, and because there are increasingly more potent less toxic antiretroviral drug options available. In LMICs, ART initiation continues to follow conservative practice. At the same time, reports from ART programmes in low-income settings continue to demonstrate great benefits in terms of survival for people with HIV. However, compared with high-income country settings, the clinical outcomes of ART in LMICs are less favourable. The enormous HIV disease burden coupled with weaker health service capability is a key challenge to expanding ART effectively, although, as ART programmes mature, there are early indications that patient outcomes may be improving. Summary In the immediate term, whether it is feasible to move to wide-scale earlier initiation of ART in LMICs remains in question; the priority for many countries is still equity and meeting the unmet needs for treatment. However, the possibility that early ART could reduce the risk of HIV transmission presents a particularly compelling incentive for earlier treatment in the high-burden settings of LMICs and further evidence on this rationale is anticipated from ongoing and planned studies.