Late introduction to ARV therapy is calamitous

VICTOR MULANGISI
Correspondent | Friday October 30, 2009 00:00

In well-resourced countries of the North the threshold is generally <350, and there is discussion of raising this level even higher. In poorly resourced countries of the South, including economic giant South Africa, it is recommended that treatment begins after someone's CD4 count dips below 200 cells/mm3.

During my recent trip to Kimberly I learnt that in South Africa, delays in initiating treatment mean that the average starting point of ARV therapy is a CD4 count of 87 cells/mm3. Dr Francois Venter, of the Southern African HIV Clinicians Society, remarked that patients in his Johannesburg clinic commence treatment at a CD4 count of 80-100 cells/mm3, a level that has not changed in four years. A study in two Durban clinics found most patients were tested at a late stage of infection with over 60 percent of CD4 counts below 200 cells/mm3. Of these patients just 42 percent had begun treatment within 12 months. The late stage at which people with HIV and AIDS in South Africa are diagnosed and the subsequent delay in getting the sufferers onto treatment has devastating consequences. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.

Currently a debate is gathering pace in South Africa regarding whether treatment guidelines should be revised to raise the CD4 treatment threshold from 200 to 350 cells/mm3. The South African National AIDS Council (SANAC), which advises the government on AIDS policy, has recommended this proposal, which is being reviewed by the National Health Council.

One projection compared raising the treatment threshold to either 250 or 350 cells/mm3.The researchers' model predicted 76,000 deaths could be prevented over five years if treatment was initiated below 350 cells, compared with below 250, assuming that 30 percent of eligible patients were identified and linked to care.

Advocates of raising the treatment threshold to <350 cells acknowledge that this would require greater expenditure but would be cost effective in the long run. A representative from the Treatment Action Campaign said: 'This is going to be expensive to implement, but these recommendations will eventually lead to cost savings. It's a cost that has simply been deferred.'

Others, such as Dr Venter, argue that amending guidelines to raise the treatment threshold neglects the fact that many patients are currently starting treatment long after becoming eligible for it, only once they have become seriously ill. Venter has also said there are reservations among doctors about earlier treatment using the antiretroviral drug, stavudine (or d4T), used in South Africa's first-line treatment, which has major side effects.

In Zimbabwe, cotrimoxazole preventive therapy is proving beneficial for HIV-infected individuals with CD4 cell count below 200-250 per mm3. This is because CPT prevents Pneumocystis (known in the recent past as carinii) pneumonia and other common bacilli infections in immune suppressed persons. This drug is well tolerated and taken until there is indication of strengthened immunity as a response to ARV treatment. Usually chances of co-infection are high where CD4 count is less 200 cells/mm3.

Tuberculosis quickly projects its ugly head to a person with immuno-suppression. As a result, it is germane for researchers and individual country think tanks to recommend that ARV therapy be initiated as soon as the CD4 count has been detected to be slightly less than 350. During this period the person will be clinically ill though stable. Side effects of these drugs are high and need to meet relatively strong properties in the body for swift response to treatment.

While many governments in developing countries may develop cold feet to endorse the decision citing their weak balance sheets, the present start up point is not all-embracing.Early entry onto ARV therapy reduces wanton mortality and scares away morbidity, thereby stabilising productivity on the economic front. Again orphan statistics is tremendously curtailed bringing more respite to governments whose coffers are dwindling on daily basis.

Parents on ARVs are masters of their own destiny and families. Accepting their status is a plus to individual government's fiscal burden; a prudent domino effect. It is no secret that people living with HIV and AIDS (PLWHAS), just like the negative ones, do not know their eventual 'home'. As governments support them in the provision of the necessary drugs so they reciprocate by giving love to their dependents as well as planning for their future. PLWHAS are turned into economists by nature of understanding their condition better than their empathizers and sympathizers.

Initiating ARV treatment is tantamount to burning a candle at both ends. Access to drugs is a great political issue therefore it is not wisdom to wait until the patient is bed-ridden to dispense COVIRO or TRIVIRO as a means of striking the balance.
(Sila Press Agency)