While WHO recommendations are to treat people earlier and
earlier, it will considerably increase the number of HIV infected people
eligible for antiretroviral therapy (ART). In South Africa, a country which
carries one of the highest HIV burden worldwide, very few studies are available
on the impact of the ART guidelines on time to ART initiation in both
individuals with low CD4 count and those newly eligible for ART. We thus aimed
to describe ART initiation percentages in a large HIV programme in rural
KwaZulu-Natal, South Africa, according to the temporal changes of national ART
eligibility guidelines from 2007 to 2012.
Adults who accessed the decentralized Hlabisa HIV treatment
programme in 2007–2012 were included. Three periods following the temporal
change of ART eligibility guidelines were defined (Period 1: until April 2010;
Period 2: April 2010 - July 2011; Period 3: from August 2011). Percentages of
ART initiation within three months of programme entry were estimated in men, in
women of childbearing age (<40 years old) and in older women, and
stratifying by CD4 count. Trend tests and logistic regression models were used
to study the effects of change of guidelines on ART initiation percentages.
In individuals with CD4 count ≤200 cells/μL (N = 5709 men, N = 6743
women <40 years old
and N = 2017 older women), percentages
of ART initiation did not differ over time (p trend = 0.25;
0.28; and 0.14, respectively). In individuals with CD4 count = 201–350 cells/μL (N = 2680
men, N = 6086 women <40 years old and N = 1415
older women), percentages of ART initiation significantly increased over time
(p trend <0.01 for the three groups): from 6 % in Period 1 to 20 % in Period 2 to 40 % in Period 3 in women of childbearing age, and from 7 % to 8-10 % to 42 % in men and in
older women.
As temporal changes of guidelines, percentages of ART
initiation significantly increased in newly ART eligible people and did not
decrease in individuals with very low CD4 counts. It will be crucial to
continue verifying the evolution of these percentages of ART initiation with
future recommendations reaching near-to-universal access to ART, to ensure that
individuals most in need of ART receive it.
Below: Percentages of ART initiation for each groups (men, women <40 years old, women ≥40 years old), stratified by CD4 count level and entry period. HIV Hlabisa programme. KwaZulu-Natal, South Africa. 2007–2012
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By:
1INSERM U897 – Centre Inserm Epidémiologie
et Biostatistique, Bordeaux, France
2Institut de Santé Publique, d’Epidémiologie
et de Développement (ISPED), Université Bordeaux, Bordeaux, France
3Africa Centre for Health and Population
Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa
4Department of Global Health and Population,
Harvard School of Public Health, Boston, Massachusetts, USA
5INSERM, UMR_S 1136, Pierre Louis Institute
of Epidemiology and Public Health, Team of research in Social Epidemiology,
Paris, F-75013, France
6Pierre Louis Institute of Epidemiology and
Public Health, Team of research in Social Epidemiology, Sorbonne Universités,
UPMC Univ Paris 06, UMR_S 1136, Paris, F-75013, France
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