Abstract
BackgroundWhile WHO recommendations are to treat people earlier and earlier, it will considerably increase the number of HIV infected people eligible for antiretroviral therapy (ART). In South Africa, a country which carries one of the highest HIV burden worldwide, very few studies are available on the impact of the ART guidelines on time to ART initiation in both individuals with low CD4 count and those newly eligible for ART. We thus aimed to describe ART initiation percentages in a large HIV programme in rural KwaZulu-Natal, South Africa, according to the temporal changes of national ART eligibility guidelines from 2007 to 2012.MethodsAdults who accessed the decentralized Hlabisa HIV treatment programme in 2007–2012 were included. Three periods following the temporal change of ART eligibility guidelines were defined (Period 1: until April 2010; Period 2: April 2010 - July 2011; Period 3: from August 2011). Percentages of ART initiation within three months of programme entry were estimated in men, in women of childbearing age (<40 years old) and in older women, and stratifying by CD4 count. Trend tests and logistic regression models were used to study the effects of change of guidelines on ART initiation percentages.ResultsIn individuals with CD4 count ≤200 cells/μL (N = 5709 men, N = 6743 women <40 years old and N = 2017 older women), percentages of ART initiation did not differ over time (p trend = 0.25; 0.28; and 0.14, respectively). In individuals with CD4 count = 201–350 cells/μL (N = 2680 men, N = 6086 women <40 years old and N = 1415 older women), percentages of ART initiation significantly increased over time (p trend <0.01 for the three groups): from 6 % in Period 1 to 20 % in Period 2 to 40 % in Period 3 in women of childbearing age, and from 7 % to 8-10 % to 42 % in men and in older women.ConclusionsAs temporal changes of guidelines, percentages of ART initiation significantly increased in newly ART eligible people and did not decrease in individuals with very low CD4 counts. It will be crucial to continue verifying the evolution of these percentages of ART initiation with future recommendations reaching near-to-universal access to ART, to ensure that individuals most in need of ART receive it.
Highlights
While World Health Organization (WHO) recommendations are to treat people earlier and earlier, it will considerably increase the number of HIV infected people eligible for antiretroviral therapy (ART)
It is important to verify that the time to ART initiation in people with low CD4 count is not longer as the number of newly ART eligible people is increasing with expanded recommendation, and that people who become eligible with higher CD4 count initiate ART quickly even if they do not feel sick [16]
ART eligibility has been assessed according to the SA national guidelines: CD4 count ≤200 cells/μL or WHO stage IV until April 2010; expansion to CD4 count ≤350 cells/μl for people with tuberculosis (TB) and pregnant women from April 2010 [18]; and further expansion to all adults with CD4 count ≤350 cells/μl from August 2011 as per the 2010 WHO guidelines [12]
Summary
While WHO recommendations are to treat people earlier and earlier, it will considerably increase the number of HIV infected people eligible for antiretroviral therapy (ART). In South Africa, a country which carries one of the highest HIV burden worldwide, very few studies are available on the impact of the ART guidelines on time to ART initiation in both individuals with low CD4 count and those newly eligible for ART. With the evidence of less sideeffects, the expansion of ART recommendations was suggested in 2006 and reinforced in 2010 for individuals with a CD4 count lower than 350 cells/μL, when most people are still asymptomatic [11, 12]. As WHO recommendations are to treat earlier and earlier in the course of the HIV infection, it is critical to inform public health decision-makers of the impact of recommendations changes on time to ART initiation. It is important to verify that the time to ART initiation in people with low CD4 count is not longer as the number of newly ART eligible people is increasing with expanded recommendation, and that people who become eligible with higher CD4 count initiate ART quickly even if they do not feel sick [16]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
