4Risk and benefits assessment

Recommendation: People living with HIV with CD4 counts >350 cells/mm3 should receive ART to prevent active TB
Population: People living with HIV with CD4 counts >350 cells/mm3
Intervention: Antiretroviral therapy
FactorDecisionExplanation
Quality of evidenceHighThe reduction in tuberculosis incidence is supported by HIGH quality randomized trial evidence
Benefits or desired effectsStrong (benefits outweigh risks)Reduction in tuberculosis incidence.

Additional benefits of ART in reducing mortality, other HIV related morbidity, and HIV transmission
Risks or undesired effectsReduction in tuberculosis incidence.

Additional benefits of ART in reducing mortality, other HIV related morbidity, and HIV transmission
Values and preferencesVariableImproved quality of HIV treatment and care.

Also prevents life-threatening opportunistic infections, increases survival, and prevents HIV transmission to others

Life-long therapy with issues of adherence and side effects in the long term.

High pill burden when ART taken with other preventive or curative treatment.
CostsWeakCosts will increase as the volume of patients will at least double, with impact on drug and non-drug costs.

Evidence on long run cost savings only demonstrated by mathematical modelling.

Cheaper interventions exist such as isoniazid preventive therapy which is yet to be scaled-up
FeasibilityWeakA move to CD4 threshold >350 for ART initiation will at least double the number of eligible patients to start ART. In a context of low uptake, late presentation for treatment and limited resources in majority of high HIV prevalence settings, it can generate confusing messaging, competing forces in terms of infrastructure demand and very serious issues of equity towards patients with lower CD4 counts and who have not accessed yet ART
Not recommended

From: Annex 1, Earlier initiation of antiretroviral therapy prevents active tuberculosis in people living with HIV – summary of findings and evaluation of the quality of the evidence

Cover of WHO Policy on Collaborative TB/HIV Activities
WHO Policy on Collaborative TB/HIV Activities: Guidelines for National Programmes and Other Stakeholders.
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