This 2010 update of the original 2006 publication by the World Health Organization (WHO) outlines a public health approach to the delivery of anti-retroviral therapy (ART) for adults and adolescents in settings with limited health systems capacity and resources. The recommendations encourage earlier HIV diagnosis and earlier antiretroviral treatment, and promote the use of less toxic regimens and more strategic laboratory monitoring. The guidelines identify the most potent, effective and feasible first-line, second-line and subsequent treatment regimens, applicable to the majority of populations, the optimal timing of ART initiation and improved criteria for ART switching, and introduce the concept of third-line antiretroviral regimens. The primary audiences are national treatment advisory boards, partners implementing HIV care and treatment, and organisations providing technical and financial support to HIV care and treatment programmes in resource-limited settings. WHO notes that it is critical that national ART programme and public health leaders consider these recommendations in the context of countries’ HIV epidemics, the strengths and weaknesses of health systems, and the availability of financial, human and other essential resources and adapt the guidelines carefully. It is similarly important to ensure that the adaptation of these guidelines do not stifle ongoing or planned research, since the new recommendations reflect the current state of knowledge and new information for sustainability and future modifications of existing guidelines will be needed.
Equity and HIV/AIDS
This study compares effectiveness of antiretroviral therapy (ART) services between primary healthcare (PHC) facilities and hospitals in low-income settings. A retrospective cohort study was conducted including ART-naïve adults from 59 facilities in four provinces in South Africa, enrolled between 2004 and 2007. A total of 29,203 adults from 47 PHC facilities, nine district hospitals and three regional hospitals were included. Patients at PHC facilities had more advanced WHO stage disease when starting ART. Retention in care was 80.1%, 71.5% and 68.7% at PHC, district and regional hospitals respectively, after 24 months of treatment. The study concludes that ART outcomes were superior at PHC facilities, despite PHC patients having more advanced clinical stage disease when starting ART, suggesting that ART can be adequately provided at this level and supporting the South African government's call for rapid up-scaling of ART at the primary level of care. Further prospective research is required to determine the degree to which outcome differences are attributable to either facility level characteristics or patient co-morbidity at hospital level.
The aims of this study were to determine the relative incidence of tuberculosis (TB) by HIV or anti-retroviral therapy (ART) status and the effect of the ART roll-out on TB incidence trends in Karonga District, Malawi. Data from the Karonga Prevention Study was analysed, including TB epidemiological studies done since 1985 and data on ART services available since 2005. The study found that relative incidence of TB was high early after initiation on ART and decreases with time, but still remains elevated. Recommendations include starting ART earlier, further collaboration between and greater integration of TB and ART programmes, and intensified case finding for TB in high-risk populations of patients receiving ART.
Recent preliminary results of Caprisa's study of the microbicide gel, Tenofovir, which showed that it can protect women from HIV infection by about 39%, have sparked concern that people might be less cautious about the use of condoms. Communities activists say condoms are already being used sparingly, with some suggesting that use of the gel might worsen the rate of condom use. Vusi Msiza, a South African community activist from Kwa-Tema, on Gauteng’s East Rand, said that the results have brought hope, but cautioned that they could also create a misperception. He urged that the message needs to be clear: there is a need to advocate use of the gel, but he also urged men to take initiative by using condoms. But other members of his community have hailed the results of the Caprisa study, saying it will give women some power as there are perceived stereotypes in using condoms. Charles Hlatshwayo who is part of a community advisory board on clinical trials in Soweto, said that the results spell good news. However, he cautioned that there might be resistance towards using the gel.
This paper’s objective was to assess the age and gender differences of clients accessing mobile HIV counselling and testing (HCT) compared with clients accessing facility-based testing, and to determine the difference in HIV prevalence and baseline CD4 counts. A prospective observational cross-sectional study was conducted of three different HIV testing services in Cape Town. The researchers compared data on age, sex, HIV status and CD4 counts collected between August and December 2008 from a mobile testing service (known as the Tutu Tester), a primary health care clinic, and a district hospital. A total of 3,820 individuals were tested. Of the HIV-infected individuals from the mobile service, 75% had a CD4 count higher than 350 cells/µl compared with 48% and 32% respectively at the clinic and hospital. Age- and sex-adjusted risk for HIV positivity was 3.5 and 4.9 times higher in the clinic-based and hospital-based services compared with the mobile service. The authors conclude that mobile services are accessed by a different population compared with facility-based services. Mobile service clients were more likely to be male and less likely to be HIV-positive, and those infected presented with earlier disease.
Kaposi's sarcoma (KS), an HIV-related cancer, is neglected in HIV and AIDS services in Africa, according to Medicines Sans Frontiers (MSF). How to administer chemotherapy at a small rural clinic is just one of the many difficulties faced by health workers treating patients with KS at 10 health facilities run by Medicines Sans Frontiers (MSF) in the Chiradzulu district of southern Malawi. Other challenges are the lack of infrastructure and safety equipment for injection-driven chemotherapy, poor case management and problematic drug supplies. MSF research, which was presented at the meeting of the Rural Doctors Association of Southern Africa (RuDASA) in Swaziland in August, found that about 7% of 11,100 ARV patients surveyed in Thyolo district had KS. Dr Francois Venter, head of the Southern African HIV Clinicians Society, said that the incidence rate in Africa is still lower than developed countries, but because of the sheer number of patients and because they present so late for treatment, KS remains an ever-present danger. He noted that the cancer was difficult to manage even in better-resourced healthcare settings like academic hospitals. MSF is now planning to train palliative care teams to handle difficult cases, and to develop a protocol to guide health workers regarding the special needs of KS patients, including how to dress lesions.
Self-tests for HIV in South Africa are currently unregulated. Gaps in law and policy have created a legal loophole where such tests could effectively be sold in supermarkets, but not in pharmacies. At the same time, South Africa lacks an effective regulating mechanism for diagnostic tests, which brings the quality and reliability of all self- tests into question. The authors argue for greater access to, and availability of, quality HIV self-tests, despite drawbacks like increased risk of unmanaged anxiety with potential for suicide if a positive result is given, lack of counselling and possible family coercion into testing. They argue that self-testing will lead to earlier diagnosis of HIV status and earlier enrolment into treatment, and decrease the costs associated with traditional voluntary counselling and testing, and allay fears about stigma and confidentiality when testing in public facilities.
This study investigated the factors associated with uptake of antiretroviral therapy (ART) through a primary healthcare system in rural South Africa. Detailed demographic, HIV surveillance and geographic information system (GIS) data was used to estimate the proportion of HIV positive adults accessing antiretroviral treatment within northern KwaZulu-Natal, South Africa in the period from initiation of antiretroviral roll-out until the end of 2008. Demographic, spatial and socioeconomic factors influencing the likelihood of individuals accessing antiretroviral treatment were explored using multivariable analysis. Mean uptake of ART among HIV positive resident adults was found to be 21.0%. Uptake among HIV positive men (19.2%) was slightly lower than women (21.8%). An individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility. Despite concerns about the equitable nature of antiretroviral treatment rollout, the study identified very few differences in ART uptake across a range of socio-demographic variables in a rural South African population. However, even when socio-demographic factors were taken into account, individuals living further away from primary healthcare clinics were still significantly less likely to be accessing ART.
Recent guidelines recommend that all HIV-infected women should receive highly active antiretroviral therapy throughout pregnancy and lactation, irrespective of whether or not they need it for their own health. This strategy for prevention of mother-to-child transmission (PMTCT) of HIV is more effective than the well-established use of single-dose nevirapine, but it is also a more costly alternative. In this economic evaluation, the researchers used a decision model to combine the best available clinical evidence with cost, epidemiological and behavioural data from Northern Tanzania. It found that a highly active antiretroviral therapy-based PMTCT Plus regimen is more cost effective than the current Tanzanian standard of care with single-dose nevirapine. Although PMTCT Plus is roughly 40% more expensive per pregnant woman than single-dose nevirapine, the expected health benefits are 5.2 times greater. The incremental cost effectiveness ratio of the PMTCT Plus intervention is calculated to be US$4,062 per child infection averted and $162 per disability-adjusted life year.
The results of the Centre for the AIDS Programme of Research in South Africa (CAPRISA) 004 tenofovir gel trial showed a 39% reduction in new HIV infections, and are considered a critical first step to getting an effective HIV prevention method for women. Much more research still needs to be done, CAPRISA cautions. As a follow-up to the CAPRISA 004 tenofovir gel trial, the global microbicide community has yet to define the quickest route to getting tenofovir gel to the public. There was consensus among the community members that confirmatory trials and implementation studies are urgently needed. However, a key challenge is insufficient funding to undertake the critical next steps. The proposed research is expected to cost approximately US$100 million over three years, of which only $58 million has been committed so far.