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Prompt start to ART essential - studies
PlusNews
February 23, 2010

http://www.plusnews.org/report.aspx?ReportID=88168

Many HIV-positive African patients are starting treatment too late for it to be effective, new scientific studies have shown.

Studies from South Africa, Uganda and Zimbabwe presented at the 17th Conference on Retroviruses and Opportunistic Infections in San Francisco (ended 19 February), all found late enrolment of patients on life-prolonging antiretroviral treatment (ART) to be a significant barrier to treatment programmes.

"Over each calendar year, we see increasing numbers of patients [enter] the programme," Suzanne Ingle, from the University of Bristol in the UK, who co-authored a study on pre-treatment mortality in South Africa's Free State Province, said via webcast. "However, there are still many deaths that occur in the period while waiting to start treatment; these deaths are most likely to occur in the most immuno-suppressed patients."

Patients with stronger immune systems - measured by a higher number of CD4 cells per cubic millilitre of blood - were not monitored frequently enough to enrol them for treatment at the correct time, Ingle said.

During the study, almost 3,000 of 22,000 participants had CD4 counts better than 250 - the then nationally stipulated threshold - and so did not start treatment immediately.

"The median time to their next CD4 measure was six months; however, within this time patients had experienced a median CD4 cell decline of 113," Ingle added. "By the time these patients were assessed again, a large proportion of them would have dropped to well below the treatment eligibility threshold."

Patients with CD4 counts below 200 are at high risk of opportunistic infections. The World Health Organization (WHO) recently reviewed its treatment guidelines to recommend that treatment start sooner, at a CD4 level of 350.

Ingle noted that "loss to follow-up" - where patients starting HIV care turn up for a first visit and are not seen again - was also a significant problem.

Late enrolment, poorer results

Presenting findings from a Development of Anti-Retroviral Therapy (DART) in Africa trial in Uganda and Zimbabwe, Paula Manderi from the Uganda Virus Research Institute said patients starting treatment with very low CD counts were unable to see their immune counts recover to levels above 250.

"If a patient still had a CD4 count of below 50 cells after a year of treatment, there is only a 9 percent chance that they would ever attain 250 cells," she said via web cast.

A CD4 cell count of below 125 after a year of treatment was identified as the cut-off point at which patients were unlikely to reach 250.

"Our data highlights the importance of expanded earlier diagnosis and earlier initiation of treatment at higher CD4 counts," Manderi said.

Ingle suggested that pre-ART mortality could be reduced by fast-tracking the most immune-deficient patients, raising the treatment eligibility guidelines in line with the new WHO recommendations, and improving monitoring and retention of patients not yet eligible for ART.

According to the WHO, almost three million people in sub-Saharan Africa are enrolled in ART programmes, which represents 44 percent of people who need treatment.

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