title: Changing Antiretroviral Eligibility Criteria: Impact on the Number and Proportion of Adults Requiring Treatment in Swaziland.
abstract: OBJECTIVE
  Early initiation of antiretroviral treatment (ART) at CD4 cell count ≥ 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment.
  
  
  METHODS
  A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012.
  
  
  METHODS
  Eight to 12 months after a national survey to determine adult HIV prevalence, 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4 cell enumeration, VL measurements, and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (≥ 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission.
  
  
  RESULTS
  Of the 927 (87% of 1067) participants enrolled, 466 (50%) reported no ART use. Among them, 424 (91%) had VL ≥ 1000 copies per milliliter; of these, 148 (35%) were eligible for ART at the then existing CD4 count threshold of <350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4 criterion of <500 cells per microliter; and 169 (40%) remained ART ineligible. Thus, 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4 criterion of <500 cells per microliter.
  
  
  CONCLUSIONS
  A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART.
authors.affiliation: *Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA; †Statistical Center for HIV/AIDS Research and Prevention and the Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA; ‡Ministry of Health-Swaziland, Mbabane, Swaziland; §ICAP-Columbia, Mailman School of Public Health, Columbia University, New York, NY; and ‖Centers for Disease Control and Prevention, Mbabane, Swaziland.
authors.forename: Naomi N
authors.initials: NN
authors.lastname: Bock
authors.forename: Ruth C
authors.initials: RC
authors.lastname: Emerson
authors.forename: Jason B
authors.initials: JB
authors.lastname: Reed
authors.forename: Rejoice
authors.initials: R
authors.lastname: Nkambule
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Donnell
authors.forename: George T
authors.initials: GT
authors.lastname: Bicego
authors.forename: Velephi
authors.initials: V
authors.lastname: Okello
authors.forename: Neena M
authors.initials: NM
authors.lastname: Philip
authors.forename: Peter D
authors.initials: PD
authors.lastname: Ehrenkranz
authors.forename: Yen T
authors.initials: YT
authors.lastname: Duong
authors.forename: Janet S
authors.initials: JS
authors.lastname: Moore
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Justman
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D013541:Eswatini / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D015995:Prevalence; D019562:Viral Load; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents