South Africa's adoption of the World Health Organization's 'test and treat' guidelines: are we too ambitious?
To the Editor: Health minister Dr Aaron Motsoaledi has announced that South Africa will adopt the World Health Organization (WHO)'s new 'test and treat' guidelines from September 2016, enabling all patients living with HIV to be eligible for antiretroviral therapy (ART).
This radical policy change is evidenced by the Strategic Timing Anti-Retroviral Treatment (START) study,  a 2011 trial conducted in 35 countries with 4 685 participants, half of whom initiated ART immediately when diagnosed with HIV and the other half as soon as their CD4 count dropped <350 cells/[micro]L. The study indicated a beneficial effect of immediate ART for both AIDS-related and non-AIDS-related events, and also reported no increased rates of adverse effects associated with this strategy. This evidence was so compelling that the trial was stopped prematurely, as it was unethical to delay ART to those not on treatment.
It has been suggested that the 'test and treat' guidelines hold the potential to eliminate the epidemic by breaking the cycle of HIV transmission and reducing ART costs in the long term; however, numerous modelling studies have found contradictory evidence to the WHO model, which under-estimated the survival time on ART and ignored the threat of resistance developing after widespread ART use. [2,3] Furthermore, it is not clear how the already overstrained healthcare system will deal with a high influx of patients on treatment, who would require baseline CD4 count testing as well as virological monitoring. A drastic increase in patient turnover could result in resources being further strained, especially with regard to clinical and laboratory capacity. This may result in the patients most at risk of death with comorbidities and low CD4 counts being missed by the healthcare system.
It is suggested that before implementing a 'test and treat' strategy, which may not be sustainable, achieving universal access to treatment with gradual increments in CD4 criteria later on may be more effective in eliminating the epidemic. However, the policy wheels were already in motion from September, and it is now more important than ever that clinicians maintain vigilance to diagnose HIV-infected patients at a high risk of poor outcomes in the midst of an influx of generally healthier HIV-infected patients.
5th-year MB ChB student, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
[1.] Lundgren JD, Babiker AG, Gordin F, et al Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med 2015;373(9):795-807. DOI:10.1056/NEJMoa1506816
[2.] Dodd PJ, Garnett GP, Hallett TB. Examining the promise of HIV elimination by 'test and treat' in hyper-endemic settings. AIDS 2010;24(5):729-735. DOI:10.1097/QAD.0b013e32833433fe
[3.] Wagner BG, Blower S. Universal access to HIV treatment versus universal 'test and treat': Transmission, drug resistance & treatment costs. PLoS One 2012;7(9):e41212. DOI:10.1371/journal.pone.0041212
S Afr Med J 2016;106(10):952 DOI: 10.7196/SAMJ.2016.v106i10.11308
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|Publication:||South African Medical Journal|
|Article Type:||Letter to the editor|
|Date:||Oct 1, 2016|
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