Epidemiology in the news

Updated ART treatment guidelines: WHO and South Africa

New scientific evidence accumulated on the initiation of antiretroviral treatment (ART), optimal ART regimens, the management of HIV co-infection with tuberculosis (TB), and management of ART failure in adults and adolescents. Furthermore, new evidence had become available on the use of antiretroviral (ARV) prophylaxis to prevent mother-to-child transmission (MTCT) of HIV, including during breastfeeding, on the optimal time to initiate ART in individuals who need treatment, and on safe feeding practices for HIV exposed infants.

Therefore the World Health Organisation (WHO) has revised several guidelines which they presented during the XVIII International AIDS Conference held form 18-23 July 2010 in Vienna, Austria:

• ART for HIV infection in adults and adolescents (1)
• ARV drugs for treating pregnant women and preventing HIV infection in infants (2)
• ART for HIV infection in infants and children (3)

WHO now recommends starting HIV treatment when a person’s CD4 count drops below 350 cells/mm3 (used to be 200). All HIV-positive patients with TB are now recommended to start ART regardless of their CD4 cell count. Estimates developed through epidemiological modelling suggest that HIV-related mortality can be reduced by 20% between 2010 and 2015 if these guidelines are broadly implemented. However, the number of people requiring ART will increase significantly.

Earlier this year, on 1 April 2010, new guidelines for the clinical management of HIV/AIDS had already come into being in South Africa. These incorporated information of the WHO’s ‘Rapid advice: Antiretroviral therapy for HIV infection in adults and adolescents’ published in November 2009 (4). The following documents were published by the South African National Aids Council (SANAC):

• Clinical Guidelines for the Management of HIV&AIDS in Adults and Adolescents (5)
• Clinical Guidelines: PMTCT (6)
• Guidelines for the Management of HIV in Children (7)

Key changes to be rolled out under the new guidelines are:

• Phasing out the use of Stavudine (d4T) and start replacing it with Tenofovir (TDF). This will reduce side effects and the need for treatment switches. Given the negative perception of the side effects associated with d4T, this should also increase uptake and adherence.
• Initiation of ART for anyone with WHO stage 4 HIV disease (opportunistic infections) regardless of CD4 count.
• Early initiation onto ART for TB patients. TB patients will now receive ART at a CD4 count of 350. Patients with drug-resistant TB will receive ART irrespective of their CD4 count. Early access to ART will reduce TB mortality. The integration of TB/HIV services is also particularly important to reduce mortality and improve TB cure rates.
• Early treatment for pregnant women. Pregnant women with CD4 counts below 350 will be initiated on ART, and this should help reduce maternal mortality.
• Improved regimen used to prevent vertical transmission in pregnant women. Pregnant women will be initiated onto a PMTCT regimen from 14 weeks instead of 24 weeks.
• Immediate ART for HIV positive infants. All HIV-infected children under the age of one will be started on ART, irrespective of CD4 level. This intervention will directly contribute towards the reduction of infant mortality due to HIV and AIDS.

The new guidelines adopt some of the recommendations made by the WHO, most notably phasing out the use of d4T (1). However, the guidelines do not adopt all the recent WHO recommendations, which included the recommendation that all people should start treatment when their CD4 count falls below 350 wherever possible. South Africa continues to recommend that most people should start treatment when their CD4 count falls below 200, except for the exceptions mentioned above.

The other major change to the treatment guidelines is that provision will be expanded from accredited ART centres to primary health care (PHC) clinics, as contained in the HIV and AIDS and STIs (Sexually Transmitted Infections) National Strategic Plan (NSP) 2007-2011. Allowing nurses to initiate and monitor people on ART, with appropriate supervision, mentoring and support, will allow for greater equitable access to treatment, and decongest the current ART initiation sites.

References:

1. WHO. Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a public health approach (2010 revision). Geneva: WHO; 2010. Link to guideline
2. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access. Recommendations for a public health approach (2010 revision). Geneva: WHO; 2010. Link to guideline
3. WHO. Antiretroviral therapy for HIV infection in infants and children. Recommendations for a public health approach (2010 revision). Geneva: WHO; 2010. Link to guideline
4. WHO. Rapid advice: Antiretroviral therapy for HIV infection in adults and adolescents. Geneva: WHO; 2010. Link to guideline
5. National Department of Health. Clinical Guidelines for the Management of HIV&AIDS in Adults and Adolescents. Pretoria: National Department of Health; 2010. Link to guideline
6. National Department of Health. Clinical guidelines: PMTCT. Pretoria: National Department of Health; 2010. Link to guideline
7. National Department of Health. Guidelines for the Management of HIV in Children - 2nd Edition. Pretoria: National Department of Health; 2010. Link to guideline