The new guidelines were finally signed off last week after a meeting last November with the provinces, donors, HIV clinicians and other HIV experts.
For several years clinicians have been calling for the guidelines to reflect best international practice including more tolerable and effective antiretrovirals, fixed dose combinations (where three drugs are compounded into one pill), increased CD4 counts (measure of immunity in the blood) for ARV initiation and the immediate initiation of babies and toddlers onto ARVs.
“We have been called to meetings every year to review the guidelines and once we leave nothing happens,” HIV Clinicians Society President Dr Francois Venter told a recent meeting of the Budget and Expenditure Monitoring Forum (BEMF). “Finally, we see a good revision, and commitment to changing in line with President Zuma’s 1st of April deadline”.
Proposed change to the guidelines will see pregnant women with CD4 counts below 350 going onto lifelong ARVs while those above 350 will receive a prophylaxis, which means she will only be taking a selection of anti-retrovirals during pregnancy to prevent HIV transmission to the baby. Children will receive antiretrovirals as soon as they are diagnosed, a move that is expected to impact on South Africa’s poor infant mortality rate.
The guidelines also undertake to phase out d4T which doctors say has by far the most side effects, expand the use of fixed dose combinations and enable nurses and primary healthcare facilities to initiate ARVs. The proposal is that d4T be replaced with tenofovir.
People with TB will also start ARVs if their CD4 counts dips below 350.
Venter cautioned that patients still start ARVs very late. “In our Hillbrow clinic the average CD4 count at initiation is 100 and in the private sector it is between 130 and 140,” he said.
Women not yet eligible for ARVs will among others receive an annual pap smear.
Venter said there was some confusion over the use of efavirenz in women of childbearing age. The drug is currently prescribed to more than 90% of patients in the public sector.
Government is concerned about the mention in the package insert that the drug is contraindicated in the first 28 days of a pregnancy and indications are that Nevirapine will be added to the regimen. However, nevirapine has a`worse short term toxicity profile than efavirenz, causing potentially life-threatening rash or liver dysfunction in the first few weeks of therapy, according to Venter.
BEMF organiser Nathan Geffen said the new guidelines were a welcome move, but said it was shocking that the country with the largest ARV programme in the world had not updated its treatment guidelines since 2004.
He also said the guidelines for drug-resistant TB had also not been published in the past six years. Sources said the new TB guidelines were announced at the same meeting as the ART guidelines.
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