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Earlier HIV treatment is not over-burdening health services
Keith Alcorn, 2016-07-22 10:40:00
Earlier treatment initiation is not overwhelming rural
health services in South Africa, but changes in treatment eligibility criteria
alone may not increase the number of people on treatment substantially, and
more investment will be needed in testing and linkage to care to reach
treatment coverage goals, research presented this week at the 21st
International AIDS Conference shows.
The World Health Organization issued guidance in September
2015 calling for treatment for all people with HIV as soon as possible after
diagnosis. The `Treat All` guidance is now being incorporated into national
policy in numerous countries; the world largest treatment programme, in South
Africa, will begin to implement the ` Treat All` recommendations from September
Some have expressed anxiety regarding the impact of the new
recommendations on health services, and in particular, whether the volume of
new patients would crowd out sicker patients. To examine this question MSF
analysed the impact of switching from a treatment threshold of 350 CD4 cells in
2014 to a higher threshold of 500 cells, in primary health clinics in
KwaZulu-Natal, South Africa.
Sarah Jane Steele of MSF South Africa reported on the impact of
extending ART criteria on the proportion of people initiated on ART by three
months and the proportion retained in care at 12 months, comparing the periods
July-December 2013 (Before) and July-December 2014 (After). HIV diagnoses were
similar in 2013 and 2014.
In the period before the guidelines change 1090 people were initiated on
treatment. Two-thirds were women, and half of all those who started treatment
did so at a CD4 count above 350. After the guidelines change 962 people were
initiated on treatment, 52% at a CD4 count above 350.
At three months there was no substantial difference in the proportion of
people with CD4 cell counts below 350 initiated on treatment after the
guidelines change, and the total number of ART initiations increased by only
111 patients (3136 in 2013, 3247 in 2014). In 2015, however, the number of
people who started treatment fell by over 600 as a result of the redeployment
of lay counsellors responsible for HIV testing. As a consequence, the number of
people diagnosed with HIV fell – even though the number of tests carried out in
the community increased from 33,731 in 2014 to 56,183 in 2015.
MSF concluded that the change in treatment guidelines is not swamping
health facilities or crowding out patients with more advanced disease.
Further research looking at the impact of increased testing activity on
treatment initiation at other sites would provide useful information about the
effects on health services of an expanding volume of patients presenting for
Jacob Bor of Boston University presented results of a modelling exercise
based on data generated by the Africa Centre’s Hlabisa HIV Treatment and Care Programme
from August 2011 to December 2013, and national estimates of patients receiving
ART produced by the South African Department of Health. The analysis found that
without an increase in testing activity, linkage to care or changes in the
speed of treatment initiation, the likely population of people starting
treatment in South Africa would increase by just 5% per year – around 164,000
new patients – and increasing the total cost of ARV provision by around 5%.
He concluded that without demand generation among the community through
widespread education on the benefits of treatment, a further increase in
testing activity, and changes in linkage and treatment initiation, South Africa
would be unable to achieve its 90-90-90 targets.