The dramatic increase
in uptake in HCT is a major step forward, but it matters little if those people
never make it onto ART. Programmatic barriers appear to contribute to
substantial losses to follow up in the linkage between HCT and ART programmes —
resulting in a failure to initiate timely ART. Prof. Moosa cited a paper last
year in AIDS that examined factors related to commencement of ART within the
first year of a new diagnosis of HIV in an outpatient setting among ART-eligible
patients.1 Out of 1474 people who tested positive, 462 (31%) never
made the linkage to the ART programme to get their CD4 cell counts measured. At
least 583 (53%) of those who did complete the referral had CD4 cell counts
below 200. Of these, 62% did not
initiate ART within twelve months although they qualified for it. Among
ART-eligible subjects, there were 108 known deaths; 82% occurred before ART
initiation or with unknown ART initiation status.
Males or anyone
without an HIV-positive friend or family member were significantly less likely
to initiate ART within the year (knowing someone living with HIV facilitates
disclosure and increases social support).2
The same team looked
at factors associated with pre-treatment losses to care and loss to follow-up,
which they defined as failure to get a CD4 cell test within 8 weeks of
diagnosis, which occurred with nearly half the subjects testing HIV-positive
and referred to care at the sites in Durban.
The study found that people were significantly more likely to be lost to care if they lived ten or more kilometres from the
testing centre, had a history of tuberculosis treatment or were referred for
testing by a health care provider rather than self-referred. Of course, given
the high cost of transportation to the clinic, financial constraints could be
part of the reason the distance from the clinic mattered. Likewise, clinic
hours may lead to greater losses among working men, who can’t afford the time
off work.
The need for peer-based tracking systems to ensure that people complete
their follow-up to the ART site, get timely CD4 cell counts and commence treatment, was emphasised by several speakers. Clinic services also need to become
more user-friendly.
Another programmatic
challenge that will clearly have an impact on patient load and other factors is
the question of when to start treatment. Virtually everyone agrees that it
would be better for a person living with HIV to start before their CD4 cell
count falls to 200. Increasing the CD4 threshold for initiating treatment to
350 would reduce the risk of opportunistic diseases, death, serious non-AIDS
events, immune reconstitution inflammatory syndrome (IRIS), the chances of
achieving a normal CD4 count, drug related toxicities.
Furthermore the recent
results of the HPTN 052 study have confirmed that antiretroviral therapy
clearly reduces the risk of HIV transmission in couples where the HIV-positive
partner is receiving treatment.
But regardless of the
guidelines, people in South
Africa have only been coming in for care
when their CD4 cells are below 100, according to Moosa. However, this is likely
to change with more people getting tested for HIV before they start falling
ill.
“Current data is compelling enough to revisit
the debate on when to start treatment in South Africa,” said Prof. Moosa,” though the sickest must be prioritised.” At
the same time, it is logical that the one way to reduce the pool of the ill
(who consume far more health system resources) is to prevent the well from
becoming sick. It may be in the national interest to target particular groups
intensively, such as nurses and teachers, for early commencement of ART.
But even without
increasing the CD4 cell threshold, the number of patients in need of treatment
will increase — and the current doctor-based model will not be able to meet the
increasing demand for care.
An alternative in
resource-limited settings, Prof. Moosa noted, is the public health approach.
This strategy to scaling up access was promoted by WHO’s 3x5 initiative, and
has even allowed the poorest of countries, such as Malawi, to rapidly scale up ART.
The approach relies on the use of simple standardised regimens, decentralised
service delivery and the delivery of care by non-specialist healthcare workers,
including medical officers, nurses (the most practical and widely implemented
in resource-constrained countries) and community workers.
Nurse-led models of
care have been shown to be effective in the management of other chronic
diseases, such as hypertension.3 Prof. Moosa also cited the CIPRA-SA
study, concued by Ian Sanne and colleagues. CIPRA-SA was a prospective,
non-blinded, non-inferiority randomised controlled study comparing
doctor-managed versus nurse-managed ART.4 Care was either provided
by two experienced primary health-care
nurses vs. two doctors. Both groups had little or no experience with ART at the
beginning of the study, but each group received similar structured didactic and
clinical training.
“The study found that nurses
are as effective and efficient at providing ART, with regards to early
virologic failure; late virologic failure, toxicity management, and loss to
follow up,” said Prof. Moosa. (Similar findings were presented from the STRETCH
study this year at the conference and are described in a separate aryticle in
this edition). “Note however, that both doctors and nurses received
protocol-specific training, lectures on clinical management and ongoing
telephonic clinical support. To duplicate these results you need to duplicate
[the level of ] training and clinical support.”
With larger facilities
at capacity, there is a need to decentralise care, and shift more of the
workload to primary healthcare clinics, and step-down facilities.
A recent
retrospective cohort analysis study from the team at Kheth’Impilo, compared
routine adult ART in three tiers of health care sites, primary, district and
regional hospitals in four provinces from 2004-2007, with seven per cent of the
subjects on ART. Analysis of baseline characteristics showed that primary health care facilities were seeing patients that are sicker than at higher levels of care. Despite seeing a sicker population the primary healthcare sites consistently out-performed higher levels of care, with regards to better retention in care, and fewer
losses to follow-up. Mortality was similar to that seen in regional hospitals
but better than district hospitals, with comparable rates of virological
suppression.5
Since it was not a
prospective randomised study, differences in outcome could have been specific
to these facilities. Nevertheless, the data seem reassuring that “ART can be adequately provided at PHC level,”
according to Prof. Moosa.