HIV/AIDS treatment guidelines for South Africa’s public health sector are out of sync not only with those of many other countries in the region, but also with the latest research on how to most effectively treat people living with HIV.
Various studies indicating that patients who start antiretroviral therapy (ART) earlier respond better to treatment and are less likely to develop AIDS-related illnesses have led the United States, the United Kingdom and a number of countries in Africa to change their treatment protocols.
Deciding when to start a patient on life-long ARV drugs is usually based on a combination of CD4 cell count test results [which indicate the strength of the immune system] and HIV disease progression, which the World Health Organisation (WHO) has defined according to four clinical stages, with stage four being AIDS.
The WHO revised its guidelines in 2003 to recommend that a patient who has reached stage three of the disease and has a CD4 count of less than 350 should begin treatment. Most countries in the region have revised their guidelines accordingly, but South Africa’s national ART guidelines are still based on earlier WHO recommendations that ART be prescribed only for patients with stage four disease, or a CD4 count of less than 200.
In April, the Southern African HIV Clinicians Society published guidelines in the Southern African Journal of HIV Medicine recommendng that people living with HIV begin ART when their CD4 cell count drops below 350, regardless of disease progression. These guidelines are endorsed by the region’s leading HIV specialists but have no direct influence on the South African government’s ART programme.
“We’ve strongly recommended [starting treatment at a CD4 count of] 350, and we’d like the Department of Health to consider it,” said Dr Francois Venter, director of the Society. “It’s such an easy disease to treat when you treat it early; the complication rate is so much less.”
The Society’s new guidelines also recommend dropping stavudine, a first-line ARV drug, from public sector treatment programmes because of its high toxicity and sometimes severe side effects, and suggest tenofovir as a possible alternative first-line drug.
Yet a recent ARV drug tender issued by the health department was still listing stavudine as a first-line drug, and listed tenofovir, which is more expensive, only as a second-line ARV drug.
The Society’s recommendation that all pregnant HIV-positive women receive ART, regardless of their CD4 count, also contradicts guidelines for the prevention of mother-to-child HIV transmission issued by South Africa’s health department in February 2008, stating that only pregnant women with a CD4 count of less than 200 should receive ART.
According to Venter, the health department is in the process of drafting revised treatment guidelines, but a department spokesperson was unable to confirm this or provide details.
Revising the government guidelines to start patients on ARVs earlier would not have a major impact on the health department’s budget or capacity, said Venter, considering most patients presented for treatment quite late. “There’s no real waiting list in most places, but my sense is that by penalising the whole system we’re never going to be on top of things.”
Some experts have argued that starting patients on ART earlier could actually save the government money in the long term by reducing the need to treat them for opportunistic infections such as tuberculosis (TB).
Prof Robin Wood, director of the Desmond Tutu HIV Centre at the University of Cape Town, is among the clinicians who have been calling for the South African government to raise the standard of treatment set out in its guidelines. However, he pointed out that better guidelines would be meaningless without improving the quality of care and access to services.
According to Wood, the median CD4 count at which South Africans actually access ART is about 100. “People tend to just get the [HIV] test and then are left outside the health system until they get TB, or get pregnant, or get sick,” he told IRIN/PlusNews. “At the moment, it’s more acute disease management than chronic care. Within that system it’s very difficult for people to go and demand CD4 counts when they’re not really aware of the benefits of them.”
In the absence of a health system that regularly monitors HIV-infected patients, changing the guidelines was “a bit theoretical”, said Wood. “Personally, I’d like to change the CD4 count to 350, but I’m not naive enough to think it’s going to make a difference to morbidity without major changes to our health systems.”