Morbidity and mortality before and after treatment initiation: looking for the best CD4 threshold to start ART in sub-Saharan Africa.

Data from CD4-guided structured treatment interruptions strategies trials performed in industrialised and low resource countries showed that patients “off ” antiretroviral therapy (ART) had higher severe morbidity rates and higher mortality rates than those “on ” ART, even at CD4 counts higher than those currently recommended in international guidelines for ART initiation (1,2). This led many experts to suggest that the current CD4 thresholds used to recommend ART initiation might be too low. Data from European and North American cohorts (3,4), but also from sub-Saharan African cohorts (5,6) and from a recent trial in Haiti (7) concur in suggesting that 350/mm3 should be considered as the minimal CD4 threshold for initiating ART worldwide, and that the issue of starting ART earlier should be rapidly addressed through randomized controlled trials. Two such trials of very early ART (Temprano ANRS 12136 trial, and START trial) were launched in 2008-2009. Their results will not be available before several years. Meanwhile, there is some suggestion that the question “should we start earlier ” (and, “if yes, how early”) might be context-driven. In sub-Saharan Africa, the spectrum of HIV-morbidity gives specific arguments to suggest that patients with high CD4 count may benefit from ART