Home-Based HIV Counseling and Testing as a Gateway to Earlier Initiation of Antiretroviral Therapy

(See the article by Wachira et al, on pages 275–81.) Timely access to combination antiretroviral therapy (ART) represents the single most effective intervention in reducing mortality and morbidity among patients with human immunodeficiency virus (HIV) infection or AIDS. Until recently, the threshold for initiating ART in resource-limited settings was set at a CD4 T-cell count ≤200 cells/mm3, a conservative threshold that had been abandoned in wealthier settings several years earlier [1]. Randomized trial data [2] and cohort evaluations [3] that demonstrate improved survival when ART is initiated earlier provided convincing evidence for the World Health Organization to revise guidance for resource-limited settings to initiate ART at a CD4 T-cell count ≤350 cells/mm3. Most developing countries have now adopted or strive for this target threshold. More recent studies have validated this shift by demonstrating the broader benefits of earlier initiation of ART, including reduced incidence of tuberculosis [4], reduced rates of hospitalization [5], reduced likelihood of HIV transmission [6], and increased life expectancy [7].