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HEALTH: Raising the Recommended CD4 Count for ART

Nastasya Tay

PRETORIA, Dec 3 2009 (IPS) - Newborn babies in South Africa will now be treated for HIV, regardless of their CD4 count. President Jacob Zuma announced several new measures which focus on expanding the country’s anti-retroviral (ARV) programme, especially in terms of mother-to-child-transmission, and for those with both TB and HIV.

A supporter at the World Aids Day celebration held in Pretoria. Credit: Nastasya Tay

A supporter at the World Aids Day celebration held in Pretoria. Credit: Nastasya Tay

The new policies target three primary groups – babies, pregnant women, and those with TB and HIV. The first guarantees treatment for all HIV positive children under the age of one, regardless of their CD4 count. The second addresses patients with concurrent TB and HIV infections, who will receive ARVs if their CD4 count is 350 or less. The third group is pregnant HIV positive women, who, under the new policy will receive treatment if they have a CD4 count of 350 or less; or if they have symptoms – regardless of their CD4 count. They will also be put on treatment at 14 weeks of pregnancy, an increase from the current last term.

Under current legislation, all patients, regardless of their condition, only receive free ARVs if their CD4 count is less than 200. South Africa currently has the largest estimated number of people living with HIV in the world – some 5.7 million – more than 10 percent of the entire country’s population. The new measures are due to roll out from April 2010.

Michel Sidibé, executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), who was in South Africa for World AIDS Day, emphasised the centrality of prevention programmes in the battle against HIV.

On the eve of World AIDS Day, the World Health Organisation (WHO) released new protocols for anti-retroviral treatment (ART), raising the recommended CD4 count for beginning ART from 200 to 350, in order to facilitate access to the drugs for people who need it, before they get too sick.

Sidibé welcomed the decision, but warned, “with these new guidelines, the number of people in need of treatment will increase considerably. As this happens, the cost of treatment will increase significantly – not only for South Africa, but for the rest of the developing world.”

The cost of expanding treatment may affect access to the drugs and bring issues of equity to the fore, as richer and poorer countries may be able to afford to expand ARV coverage to different extents, despite the WHO protocols.

“There are issues of equity here – there cannot be two separate policies – one for rich countries and one for poor countries. The benefits of putting people on treatment earlier have been demonstrated and are very clear… This makes prevention critical – by halving the number of new infections, it will make this new course of treatment affordable for developing countries,” Sidibé said

The 2009 AIDS Epidemic Update, a joint WHO and UNAIDS report describes some encouraging statistical trends. It states that globally, infection rates have dropped by 17 percent, including a decrease of 15 percent in sub-Saharan Africa.

However, despite this drop in infection rates, globally, for every two people initiated on to anti-retroviral treatment, five people are infected.

In order to counter this trend, Sidibé asserts that we need to “do a better job of getting resources and programmes to where they will make most impact, (so) quicker progress can be made and more lives saved.”

Prevention programmes need to be targeted, and integrated into healthcare systems, as part of a combined approach, to tackle an evolving epidemic. Infections are increasing in stable couples, in older age brackets, and also particularly in ‘discordant’ couples – where one partner is HIV positive and the other negative.

The Children and AIDS: Fourth Stocktaking Report, a UNICEF publication produced in partnership with UNAIDS, WHO and the United Nations Population Fund (UNFPA), launched on the eve of World AIDS Day, highlights Sidibé’s points about prevention, and emphasises the importance of paediatric HIV care and treatment.

While children are now much higher on the global AIDS agenda, and there have been substantial increases in access to Prevention of Mother To Child Transmission (PMTCT), there are still challenges in terms of availability of treatment in resource-limited countries. Weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions in broader child and maternal health services must be addressed. While more babies are being tested for HIV, this is not being matched by early treatment.

The report confirms that girls in sub-Saharan Africa continue to be disproportionately vulnerable to HIV infection, accounting for nearly 75 percent of all infections in young people. Among its recommendations, the report calls for support to empower teens, especially girls, to identify and respond to their own vulnerabilities.

At South Africa’s World AIDS Day celebration in the capital, President Jacob Zuma echoed Sidibé’s calls for a focus on prevention, and went on to announce several new measures to expand the government’s response to the HIV/AIDS epidemic, especially for children and mothers.

These measures, due to be enacted by April 2010, bring South Africa’s policy closer to being in line with the World Health Organisation’s (WHO) new protocols. They represent a distinct policy departure for South Africa, whose approach to the epidemic was formerly characterised by former president Thabo Mbeki’s denialist policies and his questioning of the link between HIV and AIDS.

President Zuma assured the thousands gathered in Pretoria that the government would “work to ensure that all health institutions in the country are ready to receive and assist patients, and not just a few accredited ARV centres.” Under the theme of “I take responsibility”, he emphasised the importance of knowing one’s status for prevention, and called on South Africans to fight stigma and discrimination.

Queen Shiburi, a young mother from the township of Mabopane on the outskirts of Pretoria was at the World AIDS Day event in the capital with her three year old son. She told IPS that President Zuma’s speech had inspired her to get tested.

“I haven’t tested before. One of my best friends is HIV positive and if I know my status, I will be able to support her better.”

As a mother, does she think that the new policies will help stem the epidemic? “I think these new policies will work, as long as they really reach a mother before she gives birth.”

Issues of prevention and access to treatment are key. And at the heart of both, are issues of equity and dignity.

Sidibé described AIDS as an ‘epidemic of integrity’, characterised by a lack of social justice and a redistribution of opportunities. He urged South Africa to “rewrite the story of AIDS in Africa… to change the dynamic of the epidemic in the country, and on the continent.”

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