Further benefits by early start of HIV treatment in low income countries: Survival estimates of early versus deferred antiretroviral therapy

We carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35 047.Providing HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2.0 and 0.7 life years respectively.This study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.The optimal time to start treatment for HIV/AIDS has been a contentious issue since the introduction of Highly Active Antiretroviral Treatment (HAART). Initially a "hit hard and early" strategy was promoted [1]. Because of concerns about long term toxicity and fear of developing drug resistant viruses, delayed treatment starts were later recommended in clinical guidelines [2]. The delayed treatment policy implied that, in the absence of particular disease manifestations, treatment should not be started before CD4 counts dropped below 200 cells/μl. However, recent evidence indicates that this policy reduces survival compared to earlier treatment start. The World Health Organisation (WHO) revised the ART g