We recommend that individuals presenting with an AIDS-defining infection, or with a serious bacterial infection and a CD4 cell count <200 cells/µL, start ART within 2 weeks of initiation of specific antimicrobial chemotherapy .
In patients with Cryptoccocal meningitis
There was no increase in the incidence of immune reconstitution disorders (IRD) or adverse events generally with early ART initiation in ACTG 5164. However, those with intracranial opportunistic infections may be more prone to severe IRDs with early ART initiation. Some data suggest that caution should be particularly exercised with cryptococcal meningitis: two studies from sub-Saharan Africa have demonstrated an increased mortality with early ART initiation; however, both were in very different healthcare settings from the UK and one utilized antifungal regimens that would not be preferred. The COAT study highlighted those with an acellular CSF and those with a decreased Glasgow Coma Scale as being particularly prone to increased mortality with early ART initiation.
In patients diagnosed with Tuberculosis
CD4 less than 100: Start as soon as practicable
CD4 100-350: As soon as practicable, but can wait until after completing 2 months of TB treatment, especially when there are difficulties with drug interactions, adherence and toxicities