Applying National Guidelines on ART - Starting ART

Authors: David Spencer, MD; Joel E. Gallant, MD, MPH
Editor In Chief: Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: September 12, 2017 (What's New)

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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.

Introduction: The Decision to Start Antiretroviral Therapy

The overriding concept in starting antiretroviral therapy (ART) is that patients must be ready, willing, and committed to embark upon a lifetime of regular medication. The critical “start date,” once it is chosen, becomes central to the patient’s ART programme. This chapter addresses the choice of the start date, the preparation of the patient before this date, and monitoring of the patient in the initial first 6 months of the programme (until the first viral load result is available and/or the patient is stable and virologically suppressed).

The majority of South Africans (83%) use the public health sector to obtain ART. Only a small percentage (17% or 8 million) utilise the private sector, and they are required to be on a medical aid scheme; approximately 25% utilise both sectors.[Gray 2011] For healthcare workers (HCWs) employed in the public primary healthcare setting in South Africa, it is important to recognise that the situation in rural and urban areas may not always be ideal.[Peltzer 2011; Nash 2011] Several challenges (including language barriers, social supports, and either geographic or economic difficulties in presenting to care, among others) must be overcome by patients and HCWs to ensure and maintain the level of care needed to completely suppress viral load. In the public sector, there are several key players who are part of the team providing care, treatment, and support for the patient. On the other hand, in private settings, the solo physician must devote considerable time to the needs of each HIV-positive patient to achieve the same end.

Effort and intensive education of all patients enrolled in ART programmes is time well spent, and the rewards will be evident during long-term follow-up. Shortcuts in this process or rushed enrolment may result in patients missing doses or abandoning their ART as difficulties present themselves (eg, unexpected adverse events, missed opportunistic infections, poor understanding by the patient of responsibilities to self and the ART team, language barriers, economic hardships, food insecurity, home responsibilities, and/or employer commitments). Patients may be single parents and/or have other sick family members for whom they provide care. The HCW must acknowledge that a particular patient’s day-to-day life may be chaotic at times. These complexities may compromise adherence and present the HCW with challenges that must be addressed and solved.

ART regimens within the public health sector have been standardised for many years, simplifying the choice of drugs. Within the private sector, more treatment options are available. Furthermore, fixed-dose combinations and generic alternatives increase the choices available in both the private and public sectors. Aligning ART choices within these 2 sectors to the same drug combinations allows patients to move smoothly between private and public-service healthcare providers without interruption of their ART and may help to prevent errors due to inappropriate drug substitutions. The need to move to the public sector may happen if patients exhaust their private medical aid from illness and hospitalisation or lose their employment.

Upon completion of the initial workup of patients eligible for ART, patients will have to receive intensive information, education, and counselling sessions. These sessions include education about HIV and antiretroviral regimens. This is a standard practice in South Africa; however, in other countries, intensive counselling before ART introduction may not be routinely done, as the criteria to start ART have expanded to include virtually all patients, and practice has evolved to start ART early with simple, well-tolerated regimens.

Universal ART for all HIV-infected patients is now also the recommendation in South Africa. In 2015, the Southern African HIV Clinicians Society recommended that ART should be started in all HIV-infected patients (Management Guidelines).[ZA HIV Clin Soc ART 2017] The guidelines from the South African National Department of Health followed suit in 2016 when a Universal Test and Treat Strategy was implemented (Management Guidelines).[ZA NDOH UTT 2016] Within this strategy, all HIV-positive children, adolescents, and adults regardless of CD4+ cell count should be offered treatment with ART. Those with CD4+ cell counts ≤ 350 cells/mm³ should be prioritised. The guidelines specify that ART should be started as soon as possible and within 2 weeks of the initial CD4+ cell count being obtained. Current World Health Organisation (WHO) guidelines suggest “rapid” initiation—that is, within 7 days—for all patients diagnosed with HIV (Management Guidelines).[WHO Rapid Init 2017] However, both WHO and South African guidelines focus on the need for patient-centered care, that is, people should not be coerced to initiate ART immediately but should be a partner in decision making concerning their own care. The readiness of the patient to commit to lifelong therapy must be considered when recommending that he or she start ART.

For patients presenting with low CD4+ cell counts or advanced disease, the benefits of starting ART promptly must be balanced with the need for pre-ART counselling. This is reflected in the current South Africa National Department of Health HIV treatment guidelines in which those with low CD4+ cell counts (< 200 cells/mm3) and HIV stage 4 disease—these patients are designated for “fast track” treatment—that is, ART should be started within 7 days. In fact, in those settings which can support same-day diagnostic testing, ART can be started immediately for patients at high risk of opportunistic infection (Management Guidelines).[ZA NDOH HIV Tx 2015] In the period after diagnosis, intensive effort should be made to keep patients engaged in care; a meta-analysis of 29 studies from sub-Saharan showed that between diagnosis and ART initiation, between one quarter to one half of patients were lost to follow-up. Those who were eligible to start ART were more likely to be retained in care but also more likely to die.[Mugglin 2012] The WHO guidelines suggesting rapid initiation of ART also included specific recommendations for patients with advanced disease—a “package of care” for these patients. This package outlines specific diagnostic tests, prophylaxis, and adapted adherence support that is designed to address concerns for those with low CD4+ cell counts (Table 5).

For more information on the initial workup of patients eligible for ART, please click here.

For more information on the criteria for starting ART, please click here.