FHD III

Assignment II: Open Editorial Piece

Craig van Heerden
304605

Antiretroviral Treatment: Complex Considerations

I believe that South Africa is not yet ready to implement the revised WHO guidelines regarding ART
eligibility.
The new WHO antiretroviral treatment (ART) guidelines recommend expanding eligibility up to and
including those with a CD4 count of 500/ml, up from 350/ml. Some of the reasons provided for this
revision provoke serious consideration. Decreases in risk of progression to AIDS, death, TB, non AIDS
defining illnesses as well as an increased likelihood of immune recovery are the major motivating
points. Of public interest is the clear reduction in transmission, especially amongst HIVserodiscordant couples. For various reasons cost-effectiveness was also suggested but this
prediction was based on a setting within which there is a high testing uptake, high treatment
adherence and high rates of retention in care. Above these recommendations there is still priority
placed on the vulnerable groups including but not limited to lower CD4 counts, co-infections, and
pregnant or breast feeding women.
I took a brief look at the current research in order to validate these claims. All the points presented
seem to have very sound footing in some relevant literature. In particular the decrease in
transmission of HIV and TB mortality and incidence with earlier ART. There were also numerous
contraindications regarding later ART initiation. The common thread through all these points is the
necessity for effective delivery as almost every benefit mentioned is compromised if this is lacking
and further harm may be caused. For those already on treatment there are a host of issues, issues
that may be exaggerated in those who would qualify for even earlier treatment. The underlying issue
here is the inaccessibility to competent and consistent monitoring and care.
The greatest benefit for the population comes from the impact this could have on transmission as
this has been predicted by various investigations yet even this cannot be guaranteed within
circumstances that do not meet certain requirements. This will remain a complete uncertainty until
such a time that we better understand the state and relationship between those who have HIV yet
have not even been tested, those that have but are not yet eligible, and those that do qualify but
have not or cannot initiate treatment yet. There is also the possible improvement in costeffectiveness for the state yet the evidence is really poor for this claim, and almost entirely so when
these predictions are compared to what would be gained in a scenario within which the current
system is modelled at its full and effective implementation.
These are reasons to exercise caution yet my greatest concern actually lies with the individuals who
would be subject to extended ART programs. Yes, there is a great body of evidence for the case of
the individual benefits yet this can only be so if these patients are guaranteed access to the newer
lines of antiretroviral drugs as well as consistent and accurate monitoring. There are already major
issues on this front for those who currently meet the requirements. Initiating treatment on an even
greater number of HIV positive people would simply subject more people to the risks of extended
drug therapy. Accessibility is what compromises all the opportunities that lie with the new WHO
guidelines, with coverage, transport, and operating hours being cited as targets for major
improvement.
The complications that come with ill-managed extended treatment lie within drug toxicity and virus
resistance. Recent investigations have already found high levels of complex resistance present in

rural primary health care first-line ART compounded by long durations on failing drug regimens,
further emphasizing critical deficiencies in the current program quality. Furthermore, nobody is
absolutely certain about the risks of extended ART even within the recommended regimens. It is
clear that complications can only be avoided when accessible and quality health care services can be
guaranteed. South Africa is a long way away from this. Along with all of these points there really is
not a great understanding of uptake, adherence, and outcomes of the current ART in these settings.
This simply makes it less clear whether there is much to be gained from increasing eligibility. What
has been clear in the literature is that there is definitely much to be gained from improving and
optimizing the treatment for those who currently meet the criteria, especially those who are
considered a priority.
If we managed to fix the current ART delivery, not only will we better understand the implications
and outcomes of this recommendation but we may then even be in a position to deliver it.

729 Words

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