HIV Treatment

Prioritization of Treatment Initiation

Prioritization of antiretroviral therapy (ART) initiation is outlined in the chart.

CD4 provides guidance on when to start ART6:
When to start ART in adults (>19 years old) ART should be initiated in all adults living with HIV, regardless of WHO clinical stage and at any CD4 cell count.
As a priority, ART should be initiated in all adults with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and adults with a CD4 count ≤350 cells/μl
When to start ART in adolescents (10–19 years of age) ART should be initiated in all adolescents living with HIV, regardless of WHO clinical stage and at any CD4 cell count.
As a priority, ART should be initiated in all adolescents with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and adolescents with a CD4 count ≤350 cells/μl
When to start ART in children younger than 10 years of age ART should be initiated in all children living with HIV, regardless of WHO clinical stage or at any CD4 cell count:
  • Infants diagnosed in the first year of life
  • Children living with HIV 1 year old to less than 10 years old
As a priority, ART should be initiated in all children <2 years of age or children younger than 5 years of age with WHO clinical stage 3 or 4 or CD4 count ≤750 cells/μl or CD4 percentage <25% and children 5 years of age and older with WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl
Timing of ART for adults and children with TB ART should be started in all TB patients living with HIV regardless of CD4 count. TB treatment should be initiated first, followed by ART as soon as possible within the first 8 weeks of treatment.
HIV-positive TB patients with profound immunosuppression (e.g. CD4 counts less than 50 cells/μl) should receive ART within the first two weeks of initiating TB treatment.
ART should be started in any child with active TB disease as soon as possible and within 8 weeks following the initiation of antituberculosis treatment regardless of the CD4 cell count and clinical stage.

Rapid Initiation of ART

Recommendation for rapid initiation of ART:

People with no contraindication to rapid ART initiation should be fully informed of the benefits of ART and offered rapid ART initiation, including the option of same-day initiation7. Rapid ART start is especially important for people with very low CD4 cell count, for whom the risk of death is high7. Although no longer a requirement for ART initiation, baseline CD4 cell count testing should be performed to determine whether the patient has advanced HIV disease7.

Diagnosing Treatment Failure

Monitoring response to ART and diagnosing treatment failure in absence of viral load testing in individuals who are not stable on ART:

Viral load is recommended as the preferred monitoring approach to diagnose and confirm treatment failure.8 If viral load testing is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure, with targeted viral load testing to confirm failure where possible8.

In settings where routine viral load monitoring is available, CD4 cell count monitoring can be stopped in individuals who are stable on ART and virally suppressed8. A patient is considered stable on ART based on the following criteria8:

  • on ART for at least one year
  • no current illnesses
  • good understanding of lifelong adherence
  • evidence of treatment success (two consecutive viral load measurements below 1,000 copies/ml)

Identifying Immunological Failure

The role of CD4 in identifying immunological failure:

The 2016 WHO guidelines point out the role of CD4 in the identification of immunological failure for the decision to switch ART regimens9:

  • Adults and adolescents: CD4 count at or below 250 cells/µl following clinical failure OR persistent CD4 levels below 100 cells/µl
  • Children younger than 5 years: Persistent CD4 levels below 200 cells/µl
  • Children older than 5 years: Persistent CD4 levels below 100 cells/µl

Treatment Adherence

The 2016 WHO Guidelines strongly recommend to provide adherence support interventions to people on ART16. The following interventions demonstrated benefit in improving adherence and viral suppression16:

  • Peer counselors
  • Mobile phone text messages
  • Reminder devices
  • Cognitive-behavioral skills training/medication adherence training
  • Fixed-dose combinations and once-daily regime

Fill the form to download Educational wall poster outlining the new role of CD4 in the WHO Guidelines

FLOWC Poster - Section 4

Twelve Steps To CD4 Testing

WHO Guidelines CD4 Testing​

 WHO clarifies the role of CD4 in assessing risk for individuals with advanced disease, for prophylaxis for opportunistic infections, and prioritization of ART initiation.
12 steps to CD4 testing, part 1 – HIV testing

12 Steps to CD4 Testing​ Part I: HIV Testing

CD4 cell count testing at baseline remains important, because relying on clinical staging alone risks missing people with severe immune suppression.

HIV Diagnosis Becomes up to Four Times Faster Thanks to This Invention

12 Steps to CD4 Testing​ Part II: HIV Treatment

People with no contraindication should be informed of the benefits of ART and offered rapid ART initiation, including the option of same-day initiation.

12 Steps to CD4 Testing​ Part III: HIV & Opportunistic Infections

CD4 count can help to make a decision on starting and stopping of prophylaxis for opportunistic infections and vaccination

References:

6. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xxxi.

7. World Health Organization (2017): Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy, page 20.

8. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xxxiv.

9. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page 131.1.

16. World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection; recommendations for a public health approach – 2nd ed., page xlii.