AEGiS-DMG: SA behind the times on HIV treatment

Important note: Information in this article was accurate in 2008. The state of the art may have changed since the publication date.

SA behind the times on HIV treatment

Mail & Guardian Online - April 14, 2008
Belinda Beresford

South Africa's inadequate public sector anti-HIV treatment has been highlighted again this week with the release of expert guidelines on antiretroviral therapy in the region. The guidelines released by the Southern African HIV Clinicians' Society (Hivsoc) are likely to be adopted by the private sector and are in line with treatment offered by some other countries in the region, as well as developed countries. They are designed to balance the possibilities of treatment against the limitations of mass antiretroviral therapy in a resource-constrained region.

The guidelines recommend starting patients on antiretrovirals (ARVs) earlier than government prescribes and giving full anti-retroviral therapy to all HIV-positive pregnant women, even if they are healthy. The guidelines explicitly mention the problem of hepatitis-B infection, a potentially cancer-causing viral infection that infects a significant percentage of HIV-positive South Africans. Linda-Gail Bekker, editor of the Southern African Journal of HIV Medicine where the guidelines are published, said: "We should not accept second-rate standards in Africa just because we are Africans ... We are now more in line with countries in the SADC region and with the World Health Organisation [WHO]. Our national [government] guidelines are out of sync with the rest of Africa." Bekker said the government HIV-treatment protocols are based on WHO guidelines issued six years ago and since improved.

The trigger for HIV-positive patients in South Africa to start ARVs is a CD4 count -- a measure of immune system strength -- of less than 200, or the development of certain illnesses. The new guidelines are to start patients on ARVs earlier, once their CD4 count drops below 350. The change is particularly needed in South Africa because of the high levels of TB. Once the CD4 count falls to 350 it opens the door to TB, which is the biggest single killer of HIV-positive people in the country. To prevent mother-to-child transmission of HIV, the public sector still largely relies on an inadequate form of intervention, which gives a short course of one or two drugs to the mother and child. Bekker said the best option for HIV-positive pregnant women is to be on antiretroviral therapy, even if they show no signs of the disease. Reducing HIV to undetectable levels slashes the chances of the baby becoming infected to less than 1%, said Bekker. Continuing the therapy while the mother is breastfeeding can dramatically reduce transmission of the virus through breast milk and, when an infant is weaned, the mother can be safely taken off the ARVs until she needs them again for her own health.

The management of hepatitis B (HBV) infection has also come under the spotlight, with the realisation that anti-HIV treatment regimens should be tailored to accommodate patients who are also infected with Hepatitis. A high proportion of HIV-positive people are infected with hepatitis B. HBV infection can cause cirrhosis and liver cancer, and HIV-positive people are more susceptible to swifter development of both diseases. The extent of HBV infection in South Africa is unknown because so-called occult or silent infections that occur are not picked up by the standard tests for the disease. François Venter, head of Hivsoc, says the level of hepatitis infection should encourage government to negotiate cheaper access to those drugs that are most effective in combating the hepatitis virus. Bekker hoped the new guidelines, which represent consensus of the best HIV doctors in the region, would encourage government to adapt its treatment programme. She said it is particularly important to pick up drug resistance patterns that may be unique to the country or region. The use of AZT in the US as a single treatment has resulted in high levels of resistance to the drug, which are not seen in South Africa.

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