The majority of patients in low income countries start treatment at an advanced stage of HIV disease as illustrated by records from some of the treatment centres: in one treatment centre in Ivory Coast, 55% of patients were in CDC category 3 (advanced disease) at the start of treatment, in Senegal this proportion was 75%, while 68% of the patients at the Mildmay centre in Uganda had advanced disease at the start of therapy. This is due to a combination of factors such as late care seeking through fear or denial, a lack of accessible counselling and testing services so that many people are unaware of their HIV infection and the high cost of the drugs which leads to treatment being deferred.
Initiation of treatment for private patients may follow the same criteria as established in industrialised countries. At the same time, private sector patients are often advised to save scarce resources and delay initiation of ART until the occurrence of the first serious HIV related illness. In the context of clinical trials and donor-supported projects, treatment is initiated according to biological criteria determined by in-country technical committees. In Senegal, treatment for symptomatic patients is started when the CD4+ cell count is below 350/mm3 and the viral load above 10,000 copies/ml, while the eligibility criterion for asymptomatic patients is a viral load above 100,000 copies/ml. In the public health system in Brazil, the recommendation is that PLHA be treated when CD4+ cell count is between 200 and 350 cells/mm3 or if the viral load is over 50,000-copies/ml.