Reply to Patten et al

TO THE EDITOR—Patten et al described the effect of expanding the South African National antiretroviral therapy (ART) guidelines in 11 sites in Khayelitsha, South Africa, which was associated with a decrease in the proportion initiating ART late and an increase in the median CD4 + cell count at ART initiation [1]. Importantly, they highlight that despite an increasing trend in the average number of people initiating ART per month, the absolute number of patients initiating ART with advanced human immunodefi-ciency virus (HIV) disease per month remained relatively stable. These findings are consistent with ours (Figure 1A of [2]), which showed a decrease in the proportion of patients initiating ART with advanced HIV disease with virtually no change in the proportion of patients enrolling in HIV care with advanced HIV disease. Both findings likely reflect the fact that expanding treatment guidelines can affect the timeli-ness with which treatment is initiated among those already enrolled in HIV care. However, guideline expansion does not necessarily affect the timeliness with which persons are diagnosed and subsequently entering HIV care. Redoubled efforts and innovative strategies are therefore needed to promote earlier HIV diagnosis and more timely linkage to care, which could in turn promote earlier initiation of ART, among those eligible. Further studies are needed to identify reasons for late ART initiation, especially after guideline expansion, and devise interventions to mitigate them [3]. In 2013, the World Health Organization released the new recommendations promoting the expansion of ART eligibility to those with CD4 + counts <500 cells/µL, while still giving priority to those with CD4 + counts <350 cells/µL [4]. We showed differing levels of improvement in the median CD4 count at ART initiation with the expansion of national ART guidelines from 200 cells/µL to 350 cells/ µL in 2007 (Rwanda) and 2011 (Kenya) (see our Figure 3 [2]). We agree with Patten et al that with ART guideline expansion , treatment programs face the challenge of treating more patients in overburdened clinics while simultaneously dealing with a constant stream of very ill patients who require careful assessment and prompt initiation of treatment [5], and this challenge may be particularly demanding in high prevalence settings such as Khayelitsha. Although our analysis examined individual-level factors, the driving forces of advanced HIV disease at ART initiation are multifactorial. We and others have identified clinic-level and contextual-level factors as important determinants of advanced HIV disease at ART initiation …