South Africa to move to earlier HIV treatment

It is not a matter of if South Africa will move to earlier HIV treatment, but when, says Health Minister Dr Aaron Motsoaledi.

The South African government plans to introduce HIV treatment for all HIV-positive children under the age of 15 regardless of CD4 count (file photo)

The South African government plans to introduce HIV treatment for all HIV-positive children under the age of 15 regardless of CD4 count (file photo)

“We are very serious about it – we have always taken our cue from the World Health Organisation,” he told Health-e. “Since (their new guidelines) have been announced, we accepted it as the direction where we are going to go.”

In 2013, the World Health Organisation (WHO) issued new HIV treatment guidelines recommending countries start HIV patients on antiretrovirals (ARVs) sooner – when their CD4 counts, a measure of the immune system’s strength, fell below 500. The guidelines drew in part from studies that showed that HIV-positive people who started ARVs at higher CD4 counts were about 96 percent less likely to transmit the virus.

Results like these have bolstered a growing body of observational data that earlier treatment benefited HIV patients by keeping them healthier longer.

In South Africa, pregnant women and children under the age of five years can access ARVs regardless of CD4 counts. Other HIV patients must wait until their CD4 counts fall below 350.

“The question is not ‘if,’ but when we are going to do that…”

“The question is not ‘if,’ but when we are going to do that and whether we will be able to afford it but in terms of our plans, we have already taken that into consideration,” said Motsoaledi speaking at the launch of a WHO and Department of Health joint review of the country’s HIV, tuberculosis (TB) and prevention of mother-to-child HIV transmission services.

The proposed move to earlier treatment has been controversial with local clinicians cautioning the benefit to patients has not yet been proven and that it may increase ARV resistance in a country where about 40 percent of ARV patients cannot be traced after three years of being on ARVs, according to data presented yesterday in the joint review.

According to National Department of Health Deputy Director General Yogan Pillay, South Africa is also planning to start adolescents on ARVs sooner, initiating children under the age of 15 years on the life-saving drugs regardless of CD4 counts as well.

Big gains as country plays ‘catch up’

At the launch, US representatives pledged about R117 million in addition to the roughly R500 million already committed to MMC

Conducted over four months by 161 international and local experts in about half of the country’s health districts, the WHO and Department of Health joint review paints a relatively well-known picture of successes and shortcomings.

The review is the first undertaken in an African country with such high burdens of HIV and TB, according to WHO Director of the HIV Department Dr Gottfried Hirnschall. Hirnschall commended the South Africa government for its level of responsiveness and transparency in undertaking the joint review.

Since Motsoaledi ushered in what many at the review’s launch described as a “change of course” that saw South Africa scramble to catch up after years of AIDS denialism, there has been a four-fold increase in ARV coverage. With about 60 percent of TB patients co-infected with HIV, the review also found that the country made impressive gains in integrating HIV and TB services. South Africa also increased the number of drug-resistant TB treatment sites from just 11 to 63.

As South Africa celebrates ten years of ARV treatment this week, the country’s change of course under the minister has been one watched closely by the world, according to Hirnschall.

“South Africa really matters … it’s the country with the largest burden of HIV and third largest burden of TB and you have a major challenge here in South Africa to deal with this,” he said. “The  scale up that you have been able to achieve in a very short time – (while) managing an incredible catch up phase that you’ve had to deal with it – has been quite impressive.”

Key populations set to get more attention

But the review also points to continued weaknesses in HIV and TB, including low HIV and TB treatment uptake among children and adolescents. It also found  increasing numbers of extensively drug-resistant TB patients failing treatment, which often means they have run out of options to stay alive.

The country could also improve its use of the best test to monitor HIV patients’ health – HIV viral load testing. Measuring the amount of HIV in patients’ blood, viral load testing is quicker at detecting treatment failure and drug resistance than CD4 count testing.

As the country moves ahead, the review recommends focusing on populations at high risk of HIV or with low coverage treatment uptake such as men who have sex with men, adolescents and children.

At the launch, US representatives pledged about R 117 million in new funding for voluntary medical male circumcision (MMC) programmes in the country. This is in addition to roughly R500 million in bilateral support already pledged to support MMC.

The review also recommends targeted outreach to inmates, miners and health care workers who stand a higher chance of developing TB due to overcrowding and occupational exposure. – Health-e News Service.

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