Eliminating CD4 treatment thresholds for HIV is unlikely to lead to a critical mass of people living with HIV starting antiretroviral treatment (ART) in South Africa, according to an analysis led by Boston University School of Public Health (BUSPH) researchers.
A study by Africa Health Research Institute (AHRI) researchers and BUSPH colleagues, published in PLOS ONE, shows that ART uptake in rural KwaZulu-Natal (KZN) among treatment-eligible patients is low—and declines at higher CD4 counts.
In September 2016, South Africa followed World Health Organization guidelines to “treat all”—removing the CD4 count thresholds which dictated who could receive ART. However, based on the experiences of patients in rural South Africa, AHRI researchers predict that fewer than one in four newly eligible patients will initiate ART within six months of testing positive. Their results are based on analyses of data from 19,279 patients enrolled in a public-sector ART program in the Hlabisa sub-district of KZN between August 2011 and December 2013.
In Hlabisa, researchers found that raising the CD4 threshold to 500 and eliminating CD4 criteria entirely were projected to increase the annual number of initiators by 21.2 percent and 26.7 percent, respectively. By scaling the Hlabisa results by the number of ART initiators nationally in 2013 (614,000), the scientists projected increases of 130,000 and 164,000 patients, respectively. These numbers represent increases of 4.3 percent and five percent in the total population of patients receiving ART in South Africa.
While this will still benefit many thousands of patients, and is therefore of value regardless of other program changes, it is not enough to achieve, on its own, South Africa’s goals, researchers said.
“Our paper identifies substantial attrition between clinical presentation and ART initiation among treatment-eligible patients. It is likely that many of these patients have blood drawn for a CD4 count, but never return to the clinic to receive their CD4 results,” said Dr. Jacob Bor, assistant professor of global health at BUSPH and lead author on the paper.