HIV patients starting treatment with advanced illnesses highlight need to improve testing, care links, authors say

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CIDMayA letter in this month’s Clinical Infectious Diseases backs earlier findings that even as access to medicine for HIV has expanded and greatly increased the numbers of people receiving treatment for the virus, large numbers of patients still are starting treatment in advanced stages of illness that earlier treatment would have prevented. One result, the letter writers say, has been services stretched to provide care for patients already very sick while continuing efforts to expand treatment enrollment.

The letter, from Gabriela Patten of Médecins Sans Frontières, and others, recounts their findings from an analysis of the impact of 2010 World Health Organization guidelines that expanded eligibility for HIV treatment. The analysis, of data from an MSF treatment program in Khayelitsha, South Africa, showed median immune cell —  or CD4 —  counts of patients starting antiretroviral treatment climbing from 135 in 2007 to 221 in 2012. The WHO guidelines released between those years changed the threshold for beginning HIV treatment from a CD4 count of 200 or less to 350. WHO updated its guidelines again in 2013, to recommend starting treatment when CD4 counts were still as high as 500, before patients become more vulnerable to illnesses, and also expanding eligibility for children, people with TB, and others regardless of their CD4 counts. The letter recounts data, which was presented at the 2013 South Africa AIDS Conference in June, showing that numbers of patients starting antiretroviral treatment rose by 81 percent over the years between 2007 and 2012. At the same time the proportion of those patients starting treatment with advanced illness classified as “Stage 4” by WHO, and characterized by life-threatening illnesses and wasting, dropped from 21 percent to 11 percent. The average number of people starting treatment with CD4 counts under 100 each month  dropped from 89 in 2007 to 85 in 2012. The gradual rates of these improvements, the authors noted, indicates that expanded HIV treatment eligibility thresholds don’t lead to sudden and unmanageable increases in antiretroviral treatment patients. But they add, the data also show that efforts to reach more people with HIV testing and treatment need to improve.

The letter followed the journal’s publication in January of a study looking at data on more than 300,000 adults enrolling for HIV care in facilities across four African countries. That study showed median immune cell counts of patients starting antiretroviral treatment at those facilities rising from 125 to 185 between 2006 and 2011 and the proportions of patients starting treatment at advanced stages of illness dropping from 42 percent to 29 percent. But it also showed these improvements actually widened the gap between women benefiting from antiretroviral treatment and men, with the odds higher of a man having an advanced phase of disease before beginning treatment, and of having a more than year-long gap in care before starting antiretroviral treatment. The authors of that study too, which was headed by Maria Lahuerta of the Mailman School of Public Health, ICAP at Columbia University, conclude that intensified HIV diagnosis, care and pre-antiretroviral treatment retention efforts are needed.

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