South Africa’s largest HIV lobby group, the Treatment Action Campaign (TAC), is demanding that everyone infected with HIV in the country is offered antiretroviral therapy (ART) immediately after their diagnosis. Currently, less than half (3.1-million) of the country’s estimated 6.4-million HIV-infected citizens receive anti-HIV treatment, according to health department data.
This is partly because government guidelines specify that only those HIV-positive people with a CD4 count of 500 and below qualify for free treatment. A CD4 count is a measurement of the strength of a person’s immune system. Some people with HIV have also not been tested for the virus and have therefore yet to be diagnosed.
The TAC's call follows the results of a groundbreaking study that was released at the International Aids Society’s Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver this week that showed that HIV-infected people who receive treatment immediately after their diagnosis fall ill far less often than those who are put on treatment only at a later stage.
Development of cancer after delayed treatmentThe Strategic Timing of Antiretroviral Treatment (Start) study, of which the results were published in the New England Journal of Medicine, found that HIV-infected people who received delayed treatment (when their CD4 counts had decreased to 350) developed cancer at almost three times the rate than those who received immediate treatment. Tuberculosis was also three times less common among those accessing treatment immediately than participants who only did so at a later stage. According to the TAC's head of policy, Marcus Low, “the overall Aids-related events rate in the early arm was 1.8% compared to 4.1% in the delayed arm – which amounts to a relative risk reduction of 57%”.
The Start study followed 4 685 patients over a period of three years. Previous research has shown that people on antiretroviral treatment with suppressed viral loads (when the treatment is successful in preventing HIV from replicating in their bodies) are unlikely to transmit the virus to others.
“In the light of this, all HIV-positive people in South Africa should be recommended ART irrespective of CD4 count,” Low said.
According to the chairperson of Southern African HIV Clinicians Society, Francesca Conradie, the long-term benefits of “doubling the number of people on ART [in order to provide all HIV-positive South Africans with treatment]” will outstrip relatively huge initial costs. “The long-term benefits are cost effective, as preventing illness, will save money,” she said.
But in a press release issued this week, the TAC warned that a “lack of willingness” to address “political problems undermining the South African public healthcare system – and by extension the country’s Aids response" – have resulted in the public health system being “plagued by stock-outs of essential medicines, staff shortages, poor infrastructure and severe management shortcomings”. These could stand in the way of the country's antiretroviral programme being scaled up “quickly and efficiently”. “A key contributing factor to this dysfunction is that many people appear to be employed or appointed for political reasons rather than for their competence or ability and commitment to effectively serve the public,” the TAC said.
The lobby group has asked for an "urgent meeting" between the South African National Aids Council, the health department and treasury to “consider the implications of the new evidence” and to “model the cost-effectiveness and potential savings of recommending ART to all HIV-positive people in South Africa as a matter of urgency”.
National health department’s deputy director Yogan Pillay, who spoke to the Mail & Guardian from Vancouver where he is attending the International Aids Society’s conference, said he is currently part of the World Health Organisation discussions about new ART guidelines. “Once I get back home we will discuss with stakeholders and make recommendations to the health minister taking into consideration resource issues as well as operational feasibility,” he said.
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