Findings highlight critical role of earlier treatment, support value of policies adopting earlier treatment guidelines
An analysis of data from all adults in a rural South Africa HIV program over the course of eight years has shown that after guidelines widened eligibility for antiretroviral treatment, death rates within the first three months of treatment dropped.
The findings show results from World Health Organization 2010 guidelines for earlier initiation of patients on HIV-fighting medicine, and may encourage more countries to adopt policies for earlier initiation, study author Richard Lessells, of the Africa Centre for Health and Population Studies said. While conclusions from the findings can’t be projected to the results of expected continued eligibility expansions, “it is likely” that early death rates will continue to decline as the wait to begin treatment diminishes, he allowed.
The study looked at data at a KwaZulu-Natal program beginning in 2004, when eligibility for antiretroviral treatment for adults in the program was tied to an immune cell count under 200, continuing through April 2010 when it was expanded to include pregnant women and people with active tuberculosis with immune cell counts of 350 or under, and after August 2011, when eligibility was expanded again to include all people with immune cell counts under 350.
More than 19,000 people started taking antiretroviral medicine to treat their HIV through the Hlabisa HIV Treatment and Care Programme, at 17 clinics and one hospital in Northern KwaZulu-Natalthe during the time researchers examined. During the first six years patients’ median immune cell count ranged from 110 to 120 at the time they started treatment. The median count rose to 145 after eligibility expanded, and then again, to 199 after all patients with the higher immune cell counts became eligible. Deaths during the first three months of starting treatment — many because patients were already succumbing to tuberculosis or other opportunistic infections — accounted for nearly 60 percent of the deaths over the years covered by the study. During those eight years, 875 people died within three months of starting treatment. But the early death rate dropped by 46 percent from 2011 to 2012. At the same time, the immune systems of people enrolling in the program, being diagnosed and tested for the first time were less damaged, with nearly half of the adults having immune cell counts of 350 and higher, indicating, at least in part, a higher motivation across the community to get tested, with a greater likelihood of receiving treatment, Lessells said.
The study took place in the area of South Africa where research recently showed that accelerated treatment coverage to be associated with increased life expectancy and lower risk of HIV acquisition on a community wide basis. Still, research also conducted by the Africa Centre for Health and Population Studies and others in the area has also shown that as health systems extend HIV treatment to greater numbers of people, retention in care is increasingly challenged.
“It really presses home though the focus is still getting people on treatment,” Lessells said, “At the same time we need to focus on quality of care and retention.”