Prevent new infections and protect our health: HIV treatment guidelines must urgently be updated

New evidence presented this week at the International AIDS Society Conference in Rome confirms that by expanding eligibility for antiretroviral therapy (ART) we could massively reduce new HIV infections.

At present most HIV-positive people in South Africa are only eligible for ART once there CD4 counts drop below 200 – only pregnant women and people co-infected with tuberculosis are eligible for ART at CD4 counts of 350. World Health Organization guidelines recommends offering all HIV-positive patients ART at 350. TAC has long advocated for this guideline to be implemented in South Africa based on the clear health benefit to HIV-positive individuals. The new evidence that earlier treatment will also reduce new infections, makes any further delays in updating the treatment guidelines unacceptable.

Unreliable data has made it difficult to assess the rate of new infections in South Africa. What is clear is that the rate of new infections remains unacceptably high. It is estimated that over 7.5 million people will become infected over the next two decades with current interventions.[1]

Yet the new evidence demonstrates that by simply expanding eligibility criteria for ART, South Africa could massively cut new infections. The results of the HPTN052 study demonstrates that earlier ART could cut one’s risk of transmitting HIV to their partner by 96%.

The HPTN052 study divided sero-discordant couples (couples where one partner is HIV-positive and the other is not) into two groups. In the first group, the HIV-positive partner received ART immediately. In the second group, the HIV-positive partner was only given ART once their CD4 cell count dropped below 250 or he or she developed an AIDS-related illness. In the delayed group of 877 couples there were a total of 27 new HIV infections. By contrast, in the immediate group, there was only one new infection. That one transmission took place in the early months when the HIV positive partner’s viral load was still detectable. All couples were counselled to use condoms and self reported condom use was high.

This evidence convincingly shows that earlier antiretroviral therapy will reduce new HIV infections. Yet one of the challenges that governments will face in implementing earlier treatment is the late diagnosis of HIV. Many people only learn their status once they are very ill and their CD4 count has fallen below 200.

In South Africa, government has already started to tackle this challenge with the massive increase in HIV Testing and Counselling. According to government nearly 12 million people have been tested since the launch of the HIV Counselling and Testing (HCT) campaign in April last year. Given the challenges in collecting reliable data in South Africa, these figures may be slightly inflated. But it is clear that government has been successful in massively increasing access to and uptake of HIV testing.

Through the HCT campaign 1.7 million South Africans learnt that they are HIV positive.[2] By delaying the initiation of this group onto ART until their CD4 counts have fallen to 200, government is missing a crucial opportunity to prevent the onward transmission of HIV.

While earlier ART can be argued for as the only responsible public health policy to reduce new infections of HIV, it is also in the interests of the individual patient. A number of studies have shown that delaying treatment once a patient’s CD4 count falls below 350, increases  one’s risk of death and mortality.[3],[4],[5]

Delaying treatment also puts a patient at greater risk of developing opportunistic infections and AIDS-defining illnesses. A further cohort study demonstrated that time spent with a CD4 count less than 500 was independently associated with non-AIDS defining cancers.[6]

Earlier treatment will also help government in tackling the massive TB crisis faced in South Africa. Earlier treatment in the HPTN052 study cut new TB infections in half.[7]

South Africa’s policy of delaying treatment until one’s CD4 count falls to 200 is based on current budget constraints, instead of what is most therapeutically beneficial to the patient. At CD4 counts of 200, eligibility is estimated at 1.6 million. However expanding eligibility to 350 increases the number of patients eligible for treatment to 2.4 million.[8]

While expanding treatment will initially increase cost, in the long run it will likely reduce cost by reducing new infections. It will also reduce the cost and burden on the health system by not waiting until patients are ill to initiate treatment, but instead starting treatment earlier to prevent illness and mortality.

With more patients being diagnosed earlier through government’s extensive HIV Counselling and Testing campaign, delaying treatment is currently a massive, missed opportunity to begin to reduce HIV incidence. We call on government to immediately change the eligibility criteria for ART, to initiate all patients at CD4 counts of 350.

[1] T Guthrie et al. The Long Run Costs and Financing of HIV/AIDS in South Africa. June 2010

[2] K Bodibe. HCT Campaign – The numbers so far. Available at http://allafrica.com/stories/201106300715.html

[3] M May et al. Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. AIDS 2007;21:1185-97.

[4] TJ Wilkin and RM Gulick, When to start antiretroviral therapy? Clin Infect Dis. 2008 Dec 15;47(12):1580-6.

[5] When to Start. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet 2009; 373: 1352–63

[6] M Bruyard et al. Program and abstracts of the 15th Conference on Retroviruses and Opportunistic Infections (Boston, MA). Alexandria, VA: Foundation for Retrovirology and Human Health; 2008. Immunodeficiency and risk of AIDS-defining and non-AIDS-defining cancers: ANRS CO3 Aquitaine cohort, 1998 to 2006 [abstract 15].

[7] Ibid.

[8] Presentation by Dr Mbengashi (SANAC Secretariat/NDOH) at the National PLHIV Consultation on the new NSP. 27 – 28 May 2011