In his budget vote speech on Wednesday July 23 2014 Minister of Health Dr Aaron Motsoaledi made two significant announcements relating to the treatment of HIV in South Africa:
- From 1 January 2015 public sector HIV patients will be started on antiretroviral treatment once their CD4 counts drop below 500 cells/mm3. Currently treatment is provided once a person’s CD4 count drops below 350. The change brings South Africa in line with current World Health Organization (WHO) HIV guidelines.
- From 1 January 2015 HIV positive pregnant women will be started on life-long antiretroviral treatment (the so-called B+ option). Currently women with CD4 counts above 350 only take antiretroviral therapy until they stop breastfeeding.
There is strong evidence showing that HIV-positive people who are stable on treatment are extremely unlikely to transmit the virus to their sexual partners. For this reason starting treatment earlier is an important strategy in reducing the number of new HIV infections.
However, the available evidence is inconclusive on whether starting treatment at a CD4 count of 500 rather than a CD4 count of 350 benefits individuals living with HIV. The critical question of the optimal point to start treatment can only be answered by ongoing clinical trials. There are two trials currently examining this, one of which, the START trial, has several hundred participants in South Africa.
The primary reason why the Treatment Action Campaign (TAC) did not advocate for South Africa to adopt the WHO guidelines in relation to earlier treatment initiation is the uncertainty regarding whether such earlier treatment benefits patients. We are also of the view that debates about when the ideal time is to initiate treatment is of secondary concern while we are facing chronic stockouts of essential medicines, while provincial health systems are collapsing, and while the National Health Laboratory Service is facing chronic financial difficulties due to non-payment by provinces.
In light of the above:
- We welcome the fact that people living with HIV who want to access treatment at a CD4 count of 500 will be able to do so from next year.
- People starting treatment must be accurately informed about the benefits and potential disadvantages of starting treatment earlier. People must be made aware that the evidence is not yet clear whether it is better for their health to start treatment at a CD4 count of 500 or to wait until their CD4 counts drop below 350. People should also be informed that taking treatment will reduce the risk of transmitting HIV to their sexual partners.
- We call on the minister of health and provincial MECs to make public the steps they are taking to monitor and stop medicines stock outs and to co-operate properly with TAC and others in addressing the huge problem of stock-outs.
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