Saving the sickest

New national guidelines have been issued by the National Department of Health that will ensure antiretroviral therapy (ART) is prioritised for those most in need of the life-saving medications The guidelines will put an end to the selective interpretation of existing Department of Health guidelines, which have sometimes led to a delay in starting therapy for desperately ill patients.

The guidelines were developed under the aegis of the South African National Aids Council. Their release was hastened by the debacle in the Free State, which saw a moratorium on initiation of antiretroviral therapy because of a shortage of funding and drugs. Pregnant women were excluded from the moratorium — but the needs of people with advanced Aids were not consistently taken into account.

As a result hundreds of people died, says Francois Venter, head of the Southern African HIV Clinicians Society. “The Free State issue made the guidelines a little bit more urgent”, he said.

It is recommended that all public healthcare centres throughout the country urgently adopt the guidelines. “We assume that there will be clinics that are not able to adopt and execute the plans immediately and if that is the case they must give reasons and they should come up with urgent plans to adoption the new guidelines”, Venter said.

The new ART guidelines strictly state that initiation of treatment should not be delayed for more than a week in patients who fit certain criteria.

“We have seen that the urgency for treatment is not months but weeks and we need to act upon that”, said Venter.

Recent local research from the universities of Cape Town and KwaZulu-Natal has emphasised the benefits of starting ART as swiftly as possible in patients with low CD4 counts, those who are clinically very ill and those with TB. Early treatment saves people’s lives and also reduces the cost to the healthcare system.

The new criteria for immediate ART for HIV positive adults are a CD4 count lower than100 and unexplained weight loss. All pregnant women who need treatment should be started immediately. Children under the age of two should be started on ART as should those older than two but with a CD4 count of less than 100. Children and adults, who have recently been hospitalised with an AIDS-defining illness, including TB, should go on treatment.

The guidelines say all HIV patients should be offered a clinical assessment to determine how far advanced the disease is, as well as a CD4 count. Patients should not wait more than two weeks for CD4 count results.

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