Changing Antiretroviral Eligibility Criteria

Objective: Early initiation of antiretroviral treatment (ART) at CD4+ cell count greater or equal to 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment. Design: A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012. Methods: Eight to 12 months after a national survey to determine adult HIV prevalence 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4+ cell enumeration VL measurements and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (greater than or equal to 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission. Results: Of the 927 (87% of 1067) participants enrolled 466 (50%) reported no ART use. Among them 424 (91%) had VL greater than or equal to 1000 copies per milliliter; of these 148 (35%) were eligible for ART at the then existing CD4+ count threshold of less than 350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4+ criterion of less than 500 cells per microliter; and 169 (40%) remained ART ineligible. Thus 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4+ criterion of less than 500 cells per microliter. Conclusions: A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART. Copyright © 2015 Wolters Kluwer Health Inc.