Academic journal article Bulletin of the World Health Organization

Implications of Adopting New WHO Guidelines for Antiretroviral Therapy Initiation in Ethiopia/Implications De L'adoption De Nouvelles Directives De I'OMS Pour le Lancement Du Traitement Antiretroviral En Ethiopie/Consecuencias De la Adopcion De Las Nuevas Directrices De la OMS Para El Inicio De la Terapia Antirretroviral En Etiopia

Academic journal article Bulletin of the World Health Organization

Implications of Adopting New WHO Guidelines for Antiretroviral Therapy Initiation in Ethiopia/Implications De L'adoption De Nouvelles Directives De I'OMS Pour le Lancement Du Traitement Antiretroviral En Ethiopie/Consecuencias De la Adopcion De Las Nuevas Directrices De la OMS Para El Inicio De la Terapia Antirretroviral En Etiopia

Article excerpt

Introduction

In 2010, the World Health Organization (WHO) issued new guidelines for the initiation of antiretroviral therapy (ART) in adults and adolescents with human immunodeficiency virus (HIV) infection. The guidelines cover a range of issues associated with ART, including initiation of the regimen at an earlier stage of infection, updated first- and second-line drug regimens and improved criteria for switching antiretrovirals.1 This paper focuses on the CD4+ T-lymphocyte (CD4+) count used as the clinical threshold for initiating ART, which has been shifted to [less than or equal to] 350 cells/mm3 from the former standard, [less than or equal to] 200 cells/[mm.sup.3].

Studies and modelfing exercises suggest that HIV-related mortality could be reduced by 20% between 2010 and 2015 by raising the CD4+ cell threshold required for initiating ART. Another possible benefit would be reduced HIV transmission between couples and from mother to child. An increase in the CD4+ threshold and hence in the demand for treatment entails certain risks, however: a rise in treatment costs as high as 57%; the displacement of patients in urgent need of ART; longer exposure to ART, resulting in unknown side-effects and in the development of resistance mechanisms. WHO has declared that in making these revisions, a high value, over and above cost and feasibility, was placed on avoiding death, disease progression and HIV transmission.t However, implementing these guidelines is not always possible in the countries where ART is most needed.

Some studies on the feasibility of implementing WHO guidelines in resource-constrained settings have been conducted, and many of them have shown that in such settings health system constraints make it difficult to roll out the new WHO guidelines. (2,3) According to one model-based analysis that projected clinical and economic outcomes in a South African HIV-infected cohort, initiation of ART in patients with a CD4+ count of [less than or equal to] 350 cells/[mm.sup.3] provides the greatest short- and long-term survival advantage and is also highly cost-effective.2 Other studies that have explored how health system constraints impeded the roll-out of the 2006 WHO guidelines count among the barriers ART stock-outs, lack of capability for performing CD4+ counts and human resource shortages. The same factors are obviously applicable to the new 2010 guidelines. (4,5)

If countries are to adopt the new WHO guidelines, the health system will have to be equipped to conduct more HIV tests and CD4+ counts and health-care services will have to become capable of absorbing higher patient case-loads. A study using Cameroon, Kenya, Viet Nam and Zambia as examples demonstrated that the change in the CD4+ threshold for initiating ART would increase the number of patients requiring ART not only in the immediate future, but also in the long term. (4)

Context in Ethiopia

While the overall prevalence of HIV infection in Ethiopia, which is currently 2.1%, remains relatively low, the country is home to an estimated 1.1 million HIV-positive people. (6,7) Ethiopia's epidemic of HIV infection is marked by pockets of high prevalence in urban areas and among women. In 2009, the prevalence of HIV infection was 7.7% in urban areas (versus 0.9% in rural areas) and 2.8% among females (versus 1.8% among males). (8) Less than one third of Ethiopia's HIV-positive patients are currently enrolled in comprehensive care and support services. Of those among them who need ART, only 62% are receiving it, despite unprecedented government efforts in the past four years to rapidly scale up comprehensive care for patients with HIV infection and acquired immunodeficiency syndrome (AIDS) throughout the country. (9)

In response to the HIV/AIDS epidemic, the Government of Ethiopia made drastic policy shifts that set a precedent in sub-Saharan Africa. Comprehensive HIV/AIDS services; including ART, were made widely available free of charge to the country's population of nearly 80 million people. …

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