Southern African HIV Clinicians Society adult antiretroviral therapy guidelines: Update on when to initiate antiretroviral therapy

Abstract

The most recent version of the Southern African HIV Clinicians Society’s adult antiretroviral therapy (ART) guidelines was published in December 2014. In the 27 August 2015 edition of the New England Journal of Medicine, two seminal randomised controlled trials that addressed the optimal timing of ART in HIV-infected patients with high CD4 counts were published: Strategic timing of antiretroviral therapy (START) and TEMPRANO ANRS 12136 (Early antiretroviral treatment and/or early isoniazid prophylaxis against tuberculosis in HIV-infected adults). The findings of these two trials were consistent: there was significant individual clinical benefit from starting ART immediately in patients with CD4 counts higher than 500 cells/μL rather than deferring until a certain lower CD4 threshold or clinical indication was met. The findings add to prior evidence showing that ART reduces the risk of onward HIV transmission. Therefore, early ART initiation has the public health benefits of potentially reducing both HIV incidence and morbidity. Given this new and important evidence, the Society took the decision to provide a specific update on the section of the adult ART guidelines relating to when ART should be initiated.

Performance verification of the new fully automated Aquios flow cytometer PanLeucogate (PLG) platform for CD4-T-lymphocyte enumeration in South Africa

“…This will save on hands-on time, allowing laboratory staff to multitask/rotate in the context of clinical pathology services (including microbiology, chemistry and hematology) and consolidating staff time to enable the rollout of related services in the same testing facilities. The provision of reflexed screening of early opportunistic HIV co-infections such as Cryptococcal meningitis [ 53 , 54 ] with Cryptococcal antigen (CrAg) testing of all CD4 samples with counts less than 100 cells/μl is one such example. For the implementation of this national testing program no additional staff were employed in any of the CD4 laboratories, i.e.…”

“…This is especially true in the context of countries with a very high patient burden with advanced HIV disease like South Africa [ 7 ]. It is thus important to emphasize that CD4 enumeration remains an important parameter [ 54 , 63 , 67 ] to assess immune status of patients at baseline before ART initiation, and/or for identifying risk and/or screening for opportunistic co-infections such as Cryptococcal disease [ 53 , 54 ].…”

Estimating the cost-per-result of a national reflexed Cryptococcal antigenaemia screening program: Forecasting the impact of potential HIV guideline changes and treatment goals

“…Recent guideline recommendations propose that all HIV+ individuals should be eligible for treatment, irrespective of their CD4 count [ 19 ]. Local opinion leaders in South Africa continue to stress that baseline CD4 would still be required to assess immune deficiency, life threatening co-infections (such as Cryptococcal disease) and enable fast-tracking severely immune suppressed patients [ 24 ] onto ART, hence the basis of this report.…”

From the Bench to the Field in Low‐Cost Diagnostics: Two Case Studies

“…DILI associated with nevirapine-based ART-widely used in the developing world-is of particular concern; rates of nevirapineassociated hepatotoxicity (a type of liver damage) exceed 13%. [32,33] Monitoring liver function provides an important tool to manage ART; [33,34] dosages and treatments can be adjusted if signs of liver damage or hepatitis appear. Tests to monitor liver function, however, are often unavailable in low-resource settings where many patients with HIV receive care.…”