Researchers have concluded that if HIV patients start treatment earlier than the World Health Organization recommends, approximately 76,000 lives could be saved in South Africa. In addition, 66,000 cases of associated diseases could be prevented within the next five years. The study, published in the Annals of Internal Medicine and funded by the National Institute of Allergy and Infectious Diseases and the Doris Duke Charitable Foundation, truly challenges the manner in which HIV has been traditionally treated. The appropriate time to begin treatments is determined by measuring the patient’s CD4 levels. A healthy human’s CD4 levels are between 800-1200 per cubic millimeter of blood. Developed nations traditionally administer treatment to patients when the levels fall below 350. The World Health Organization (WHO) recommends starting treatment in South Africa, and other nations, when CD4 levels fall below 200 per cubic millimeter of blood.



According to Rochelle Walensky, leader of the researchers in this study, earlier treatments should begin immediately. “Waiting five years for trial results could be costly in human terms,” she said. She also explained how starting treatment earlier would also help prevent people with HIV from spreading the disease, as the ARTs would be able to reduce the levels of the virus to such low levels, that they would be harder to pass on. The number of 76,000 saved lives was determined assuming that the current infection rates of HIV in South Africa continue and also assuming that 30% of those infected are diagnosed. Approximately 5.7 million people in South Africa have HIV, more than any other nation (South African HIV/AIDS statistics here).

At the fifth IAS Conference on HIV Pathogenesis, Treatment, and Prevention, Reuben Granich of WHO also argued that viral load is the greatest risk for HIV transmission. The use of anti-retroviral drugs (ARVs) to reduce viral load would significantly reduce the spread of the disease - to the point where Granich believes incidence would reduce from 20,000 per million to 1,000 per million and the number of people living with HIV would be lower than 1% by 2050.



Dr. Francois Venter of the Reproductive Health Research Unit in Johannesburg also spoke at the conference. He used his own experience and studies to show that the debate of when to start ARVs is moot when considering that most patients in sub-Saharan Africa begin treatment very late; the average CD4 count for patients starting treatment is around 100. Studies in South Africa are showing that when patients begin treatment with CD4 levels below 200, there is massive mortality. “Below 200″ is the current South African policy. Dr. Venter says that the majority of patients are entering the treatment system with CD4 levels between 50 and 100. Venter notes that there is a poor linkage between HIV testing and access to ARVs. Dr. Andrew Boulle of the University of Cape Town agrees, “We see the largest mortality before people are enrolled onto ARVs.” A WHO article addressing the ART studies states:

“WHO will be reviewing evidence and revising guidance on ART use, including when to start, for adults and children later this year, but there are many advocates for earlier therapy. There is little doubt that ART has preventive effects; what is uncertain is how best to apply it and combine it with other evidence-based prevention interventions for maximal synergy and benefit.”



The cost of providing ARV treatment on this scale is a looming reason for delayed treatment. But Granich says, “The initial resources would be higher, but over time, given the reduction in HIV incidence, this approach may provide cost savings.” The researchers of the study cited in the Annals of Internal Medicine estimate in their conclusion that if even 10% of people began treatment when higher levels of CD4 were in their blood, the cost of treatment would increase by $142 million over the next five years (offset in part by the reduced incidence of opportunistic disease, such as TB). If 100% began earlier treatments, the additional cost over $1.4 billion, with 221,000 cases of opportunistic disease prevented and 253,000 deaths averted.