Tm initiation of art

There is some controversy about the best time to start ART. Clinicians in industrialized countries use plasma HIV RNA levels and CD4+ T-lymphocyte counts in guiding this decision. For example, a high viral load (i.e. above 30000 RNA copies/ml by RT-PCR) is an indication to start

ART.These expensive laboratory tests are used for staging HIV infection and for monitoring therapy. WHO guidelines apply in resource-limited settings where these tests may not be available. Clinical stage (see Section 1.2.7) is important as a criterion for starting ART.

11.5.1 | Adults and adolescents with documented HIV infection

Recommendations for initiating ART

CD4 testing available

WHO stage 4 irrespective of CD4 cell count WHO stagel, 2 or 3 with CD4 cell counts less than 200/mm3

CD4 testing not available

WHO stage 3 or 4 irrespective of total lymphocyte count

WHO stage 2 with total lymphocyte count less than 1200/mm3

Contraindications to starting treatment include severe renal or hepatic insufficiency, and concomitant incurable disease.

11.5.2 | Infants and children

Recommendations for initiating ART

testing

Age

HIV Diagnostic testing

Treatment recommendation

If CD4

testing is available

< 18 months

Positive HIV virological test1

HIV virological testing not available but infant HIVseropositive or born to known HIV-infected mother (Note: HIV antibody test must be repeated at age 18 months to obtain definitive diagnosis of HIV infection)

° WHO Paediatric Stage 3 (AIDS), irrespective of CD4 cell percentage2 ° WHO Paediatric Stage I disease (asymptomatic) or Stage 2 disease with CD4 percentage < 20%3 ° WHO Paediatric Stage 3 disease (AIDS) with CD4 cell percentage < 20%

> 18 months

HIV antibody seropositive

° WHO Paediatric Stage 3 disease (AIDS) irrespective of CD4 cell percentage2 ° WHO Paediatric Stage I (asymptomatic) or Stage 2 disease, with CD4 percentage <I5%3

If CD4

testing is not available

< 18 months

Positive HIV virological test1

° WHO Paediatric Stage 32

HIV virological testing not available but infant HIV-seropositive or born to known HIV-infected mother

° Treatment not recommended4

> 18 months

HIV antibody seropositive

° WHO Paediatric Stage 32

1 HIV DNA PCR or HIV RNA or immune complex dissociated p24 antigen assays, or HIV culture.

2 Initiation of ARV can also be considered for children who have advanced WHO Paediatric Stage II disease including e.g. severe recurrent or persistent oral candidiasis outside the neonatal period, weight loss, fevers, or recurrent severe bacterial infections, irrespective of CD4 count.

3 The rate of decline in CD4 percentage (if measurement available) should be factored into the decision-making.

4 Many of the clinical symptoms in the WHO Paediatric Stage II and III disease classification are not specific for HIV infection and significantly overlap those seen in children without HIV infection in resource-limited settings;thus, in the absence of virological testing and CD4 cell assay availability, HIV-exposed infants <18 months of age should generally not be considered for ART regardless of symptoms.

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