Change of treatment guidelines and evolution of ART initiation in rural South Africa: data of a large HIV care and treatment programme.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. melanie.plazy@isped.u-bordeaux2.fr.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France. melanie.plazy@isped.u-bordeaux2.fr.
Mélanie
M
Plazy
INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. francois.dabis@isped.u-bordeaux2.fr.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France. francois.dabis@isped.u-bordeaux2.fr.
François
F
Dabis
Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa. kevindra8@gmail.com.
Kevindra
K
Naidu
INSERM U897 - Centre Inserm Epidémiologie et Biostatistique, Bordeaux, France. joanna.orne-gliemann@isped.u-bordeaux2.fr.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France. joanna.orne-gliemann@isped.u-bordeaux2.fr.
Joanna
J
Orne-Gliemann
Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, KwaZulu-Natal, South Africa. tbarnighausen@africacentre.ac.za.|Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA. tbarnighausen@africacentre.ac.za.
Till
T
Barnighausen
INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France. rosemary.dray-spira@inserm.fr.|Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, F-75013, Paris, France. rosemary.dray-spira@inserm.fr.
Rosemary
R
Dray-Spira
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count; D005260:Female; D017408:Guidelines as Topic; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D009313:National Health Programs; D012424:Rural Population; D013019:South Africa; D055815:Young Adult