For HIV-infected individuals who are ART

For HIV-infected individuals who are ART-naïve and who have no history of AIDS-defining illness, current U.S. treatment guidelines recommend initiating ART when the CD4 count falls below 350 cells/μL in most cases [37]. Exceptions (for whom treatment should be initiated regardless of CD4 count) include pregnant women, persons with HIV-associated nephropathy, and those co-infected with hepatitis B requiring treatment; the guidance also cites decreasing the risk of HIV transmission to others as a potential benefit to early therapy. The use of 350 cells/µL as a minimum threshold is supported by analyses from a subgroup of participants from the Strategies for management of Antiretroviral Therapy (SMART) study, which noted that among persons with CD4 counts of >350 cells/µL, those who were randomized to deferral of ART until the CD4 count dropped to <250 href="http://www.cdc.gov/hiv/topics/treatment/resources/factsheets/art.htm#38">38]. A meta-analysis of 18 cohort studies also supports counts of 350 cells/µL as a minimum threshold [39]. Optimally, the decision to institute initiation of ART at a higher CD4 threshold on a widespread level would be based upon data from controlled studies. Recent studies indicate that initiating ART earlier than the currently recommended CD4 threshold of 350 cells/μL may confer benefits on survival [40] and immune function [41], without necessarily increasing risk of adverse events such as peripheral neuropathy, anemia, and renal insufficiency [42]. An ongoing randomized controlled study, HIV Prevention Trials Network (HPTN) 052, will compare the effectiveness of two treatment strategies in preventing the sexual transmission for HIV. Discordant couples will be randomized to either immediate ART for the infected partner, or deferral of ART until the CD4 count falls to between 200-250 cells/µL [