Applying National Guidelines on ART - Primary Care

Authors: Nathan Ford, PhD, FRCP; Victor Fredlund, MB BS (LOND); Dirk Hagemeister, BA, DipHIVMan, MPH, EMMB, FAfAllgMed
Editor In Chief: Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: July 8, 2016 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, offers physicians 3 CPD points on a 70% pass rate for completing this individual module. Nonphysicians who successfully complete the module will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.

HIV in South Africa

More than 6 million people are living with HIV and AIDS in South Africa, the highest number of people in any country in the world.[UNAIDS 2014] In 2014, 140,000 South Africans died of AIDS-related causes. HIV prevalence nationwide is 12.2% but varies by region,[SA HIV Survey] with KwaZulu-Natal, the region with the highest prevalence, having approximately 15.8% of its population infected with HIV.[UNAIDS 2014; ZA HIV Prevalence Survey 2012] At the lower end of the scale is the Western Cape, which has an HIV prevalence rate of 3.9%.

Current South African HIV treatment guidelines (issued in 2015) indicate that HIV-infected adults and adolescents with CD4+ cell counts ≤ 500 cells/mm3 or World Health Organisation (WHO) stage 3 or 4 disease should start antiretroviral therapy (ART) (Management Guidelines).[ZA NDOH HIV Tx 2015] In addition, several groups of HIV-positive persons are eligible for ART, regardless of CD4+ cell count or disease stage:

  • All HIV-positive pregnant and breast-feeding women
  • Those coinfected with tuberculosis (TB) or hepatitis B virus

National eligibility guidelines for infants and children recommend ART initiation in all HIV-infected children younger than 5 years of age and in children 5-15 years of age with CD4+ cell counts ≤ 500 cells/mm3 or WHO stage 3 or 4 disease.

The South African Strategic Plan on HIV, STIs and TB (2012-2016) has outlined a 20-year vision of initiating at least 80% of eligible patients on ART, with 70% alive and on treatment 5 years after initiation (Management Guidelines).[SANAC 2012] Currently, there are 2.9 million HIV-infected patients receiving ART.[Kaiser 2014] However, the number of eligible patients changes along with new treatment criteria, including change of CD4+ cell count at which treatment is initiated and the inclusion of a prevention indication for ART in members of serodiscordant couples. A study was performed in the North West Province to compare actual vs targeted ART initiations.[Martin 2014] The steady state need (determined by annual rate of new HIV infections in previous years) was 639 initiations/month but ~15,388 patients were backlogged. Any change in criteria for initation would change the backlog and would require additional capacity.

Current HIV treatment guidelines issued by US agencies,[DHHS ART 2016; IAS USA ART 2014] the World Health Organisation,  (Management Guidelines)[WHO ART 2015] and the Southern African HIV Clinicians Society (Management Guidelines)[ZA HIV Clin ART 2015] suggest that all HIV-infected persons be started on ART, regardless of CD4+ cell count or clinical presentation. In areas such as South Africa, if this recommendation is accepted in the public sector, it may gravely affect resources.

Issues that must be addressed by healthcare providers and policy makers in South Africa include how to identify, engage, and maintain HIV-infected persons in care, provide them with ART, and deliver comprehensive care.

For more information on the initiation of ART in HIV-infected patients, click here.

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