SA does well with HAART, but too many still dying – study

However, the study, published in Plos Medicine this week, did find that more patients died in South Africa than in Switzerland, particularly during the first three months of therapy. This is mainly due to HIV patients not being able to access treatment when needed or trying to access help when they are already desperately ill.

‘€œFurther innovation and resources are required in South Africa to both achieve more timely access to Highly Active Antiretroviral Therapy (HAART) and improve the prognosis of patients who start HAART with advanced disease,’€ said the group of researchers from the   Universities of Cape Town,   Bern and Bristol as well as Médecins Sans Frontières in Khayelitsha.

HAART, a combination of several antiretroviral drugs, was developed in 1996. This led to clinicians in resource-rich countries, such as Switzerland, being able to provide individually tailored care for HIV infected people by prescribing combinations of antiretroviral drugs from more than 20 approved medicines.

In these countries the approach to treatment also typically includes frequent monitoring of the amount of virus in patients’€™ blood (viral load), viral resistance testing (to see whether any viruses are resistant to specific antiretroviral drugs), and regular CD4 cell counts (an indication of immune system health).

Since the implementation of these interventions, the health and life expectancy of people with HIV has improved dramatically in these countries.

In resource poor countries, the history on HIV care has been very different. Initially many countries could not afford to provide HAART for their populations. South Africa only implemented HAART in the public sector at the end of 2003 after much pressure from civil society and health workers.

However, five years later, many people who need HAART are still not accessing it.Instead of individualized treatment, HAART programmes in developing countries, such as South Africa, follow a public health approach developed by the World Health Organisation.

This means that drug regimens, clinical decision-making and clinical and laboratory monitoring are all standardized.

The researchers were trying to ascertain whether this public health approach was as effective as the individualized approach.

They addressed this question by comparing virologic responses (the effect of treatment on the viral load), changes to first line (initial) therapy and deaths in patients receiving HAART in South Africa and in Switzerland.

They analysed data collected since 2001 from 2 348 patients enrolled in HAART programs in Khayelitsha and Gugulethu (in Cape Town) and from 1 016 patients enrolled in a Swiss HIV Cohort Study.

The patients in South Africa, who had a lower starting CD4 cell count and were more likely to have advanced AIDS than the patients in Switzerland, started their treatment for HIV infection with one of four first-line therapies, and about a fifth changed at least one of their first-line drugs during the first two years on HAART.

By contrast, 36 first-line regimens were used in Switzerland and half the patients experienced at least one change to their starting therapy.

‘€œDespite these differences, the viral load was greatly reduced within a year in virtually all the patients and viral rebound (an increased viral load after a low measurement) developed within 2 years in a quarter of the patients in both countries. However, more patients died in South Africa than in Switzerland, particularly during the first 3 months of therapy,’€ the researchers said.

They found that the public-health approach to HAART practiced in South Africa is as effective in terms of virologic outcomes as the individualized approach practiced in Switzerland.

 ‘€œThis is reassuring because it suggests that ‘€˜antiretroviral anarchy’€™ (the unregulated use of antiretroviral drugs, interruptions in drug supplies, and the lack of treatment monitoring), which is likely to lead to the emergence of viral resistance, is not happening in South Africa as some experts feared it might,’€ the journal editors note in their summary of the research.

The researchers said the findings supported the continued rollout of the public-health approach to HAART in resource-poor countries.

‘€œConversely, it also suggests that a more standardized approach to HAART could be taken in Switzerland (and in other industrialized countries) without compromising its effectiveness,’€ the editors said.

The researchers said that the higher mortality in South Africa than in Switzerland, which partly reflects the many patients in South Africa in desperate need of HAART and their more advanced disease at the start of therapy, suggested that HIV-infected patients in South Africa and in other resource-limited countries would benefit from earlier initiation of therapy.

There is increasing evidence that patients do better if started on therapy at CD4 counts between 200 and 350, whereas the current South African government guidelines allow for therapy after the CD4 count goes below 200 or they have an AIDS defining illness.  However the researchers note that limited access to care is a key reason HAART is not started earlier for many patients in South Africa and comment ‘€œ’€¦there is strong evidence that public health strategies to increase access [to HAART] in South Africa should be further promoted.’€   The latest UNAIDS estimate is that 28% of South Africans in need of HAART are receiving it.


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