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Early ART highly acceptable and achieves excellent rates of viral suppression among young South African women
Michael Carter, 2017-04-27 08:00:00
antiretroviral therapy (ART) is highly acceptable to the majority of young women with HIV in South Africa, according to research published in AIDS and Behavior.
Rates of virological
suppression remained at over 85% regardless of CD4 threshold for starting treatment, and answers to a questionnaire showed that over three-quarters of
participants were willing to start treatment when their CD4 count was above 500
cells/mm3. Moreover, half of patients who said they would not
consider early treatment actually started therapy with a high CD4 count.
“We found that CD4
counts at ART initiation have been dramatically increasing over the last
decade, and that concurrently, HIV viral loads have decreased, potentially
having an important impact on HIV transmission at the individual and community
level,” comment the authors. “Importantly, while women started ART earlier,
this did not have a negative impact on adherence, as demonstrated by similar
rates of virological suppression up to two years post-ART initiation regardless
of the CD4 count at treatment start.”
In 2015 the World
Health Organization (WHO) issued updated guidelines recommending immediate ART
for all HIV-positive individuals, regardless of CD4 count. The benefits of
early treatment are now well established, including a reduced risk of HIV- and
non-HIV-related illness and a low risk of onward transmission of the virus.
benefits, concerns have been voiced that patients in good health with a high
CD4 count may not see the value of early treatment and therefore be
reluctant to start treatment. There are also concerns that people in this group would have poor adherence, even if they started treatment.
the ongoing South African CAPRISA 002 cohort therefore designed a study
describing trends in CD4 count at ART initiation according to WHO and national
guidelines; to determine rates of viral suppression after ART initiation at
different CD4 levels; and using a questionnaire, to assess the perceived
benefits and acceptability of early ART.
population consisted of 232 women living with HIV, who had not previously taken HIV treatment, recruited
between 2006 and 2015. The first women started therapy in 2006 when the CD4
cell threshold for the initiation of ART was 200 cells/mm3. This
increased to 350 cells/mm3 in 2013 and to 500 cells/mm3
in 2015. Universal therapy, regardless of CD4 cell count, was recommended in
Study participants were
followed 1, 3, 6 and 12 months after ART initiation and at intervals of six
months thereafter. Viral suppression was defined as a viral load below 400
A subset of 51
women who received care in 2014-15 completed a questionnaire about the acceptability
of early ART.
two-thirds (68%) of participants started ART between January 2006 and December
2015. Mean CD4 count at ART initiation was 217 cells/mm3 before
2010, increasing to 531 cells/mm3 in 2015. Mean viral load
simultaneously decreased from 158,000 copies/ml to 12,600 copies/ml.
Rates of viral
suppression at 3, 6, 12 and 18 months after ART initiation were analysed. At
least 86% of patients had an undetectable viral load at all time points. There was no
significant difference between rates of suppression according to whether
therapy was initiated at the CD4 thresholds of 350 or 500 cells/mm3.
The 51 participants
who completed the questionnaire had a median age of 28 years. Their mean CD4
count was 590 cells/mm3 and median viral load approximately 12,600
recognised the health benefits of early ART, including a reduced risk of TB
(94%), reduced risk of illness and death (92%), reduced risk of organ disease
(84%), a reduction in the risk of HIV transmission during pregnancy and
breastfeeding (90% and 84%) and a reduced risk of HIV transmission to a sexual partner
participants were concerned about treatment side-effects (59%), the need to
take life-long therapy (37%), daily therapy (35%), having to disclose HIV
status because of treatment (57%) and a fear of stigma (57%).
Overall, 78% of
women were willing to start ART while their CD4 count was above 500 cells/mm3.
Of those, 70% said they felt ready to start treatment, with 90% stating
this was to improve their health, and 30% citing the desire the start a family.
Of the 22%
of women who said they were unwilling to start early treatment, 91% stated this
was because they felt well and therefore did not perceive a need for ART. Other
reasons included concerns about side-effects (46%), taking a large number of
pills (27%) and having to disclose HIV infection status to a partner (27%).
Most of the
participants (94%) had a current partner. Just over half (55%) knew the HIV status of their partner, with 82% of these reporting their partner
was HIV-positive. However, only 23% had a partner who was taking ART.
two-thirds of participants started ART within six months of completing the
questionnaire. This included 73% of women who said they would be willing to
consider early ART; these patients had a mean CD4 count of 717 cells/mm3
at treatment initiation. Half the women who indicated they did not want to
start early ART did in fact start therapy; their mean CD4 count was 690
cells/mm3. Just under a third (31%) did not start treatment, with a mean
CD4 count of 815 cells/mm3.
acknowledge that as their study population consisted of young women, the
findings may not be generalizable to other populations. Other possible
limitations include high levels of ART awareness among their cohort and the
small sample size.
Despite this, the
authors conclude that ART initiation at higher CD4 counts is acceptable and