Page 276 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 10 Original Research

TABLE 1: South African guidelines for treatment of adults with human immunodeficiency virus infection.
Variable 2004 guidelines April 2010 guidelines March 2013 guidelines† December 2014 guidelines‡ August 2016 circular§
ART eligibility CD4 count < 200 cells/mm 3 CD4 count ≤ 200 cells/mm 3 CD4 count ≤350 cells/mm ¶ CD4 count ≤ 500 cells/mm 3 UTT: all HIV-infected
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or or or or clients regardless of
WHO Stage IV disease CD4 count ≤ 350 cells/mm WHO stage III or IV disease WHO stage III or IV disease CD4 count
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in clients with TB/HIV or or or
pregnant women Clients with all types of TB Active TB disease
or or
WHO stage IV disease Pregnant and breastfeeding
or women
MDR/XDR-TB or
Known HBV co-infection
First-line ART regimen (new clients) d4T + 3TC + EFV/NVP TDF + 3TC/FTC + EFV/NVP FDC†† FDC††
CPT All clients initiating ART CD4 ≤ 200 cells/mm 3 CD4 count ≤ 200 cells/mm 3
WHO stage II, III or IV WHO stage III or IV disease
disease (including TB) HIV/TB co-infection
Source: National Department of Health of South Africa 5,6,7,8,9
3TC, lamivudine; ART, antiretroviral therapy; CPT, cotrimoxazole preventive therapy; d4T, stavudine; EFV, efavirenz; FDC, fixed-dose combination; FTC, emtricitabine; HIV, human immunodeficiency
virus; HBV, hepatitis B; MDR/XDR-TB, multidrug-resistant or extensively drug-resistant tuberculosis; NVP, nevirapine; TB, tuberculosis; TDF, tenofovir disoproxil fumarate; UTT, universal test and
treat; WHO, World Health Organization
†, Implementation date = 01 April 2013;
‡,Implementation date = 01 January 2015;
§, Implementation date = 01 September 2016;
¶, Implementation of the CD4 count ≤350 cell/mm cut-off occurred in August 2011, prior to the publication of the 2013 guidelines ;
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††, FDC consists of TDF, FTC and EFV.
and thereby reducing morbidity and mortality. 5,6,9 Triple- urban and rural HIV epidemics in South Africa, namely,
therapy antiretroviral drug regimens have also been updated Johannesburg and Mopani districts. Specifically, this study
over time, from combination single formulation regimens aims to use routine TIER.Net data from adult clients in an
including stavudine in 2004 and tenofovir in 2010 to a fixed- urban and rural district of South Africa to (1) describe ART
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dose combination (FDC), a single tablet containing three programme growth and baseline CD4 count over time, (2)
antiretroviral drugs (tenofovir, emtricitabine and efavirenz), analyse 5-year mortality in the context of baseline CD4 count
in 2013. As the ART programme has evolved and expanded, and (3) describe the population initiating ART at low CD4
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it has become increasingly important to have an effective counts (< 200 cells/mm ) in 2017 in order to identify priority
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monitoring system, and in 2010 the Department of Health groups at high risk of mortality for intervention.
adopted an electronic monitoring and evaluation tool known
as TIER.Net, which was developed by the University of Cape Methods
Town’s Centre for Infectious Disease Epidemiology and Study population and data source
Research. TIER.Net is used operationally to monitor
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baseline clinical care and client outcomes over time, providing Routinely collected data from adults initiating ART in two
a rich source of cross-sectional and longitudinal routine districts of South Africa, Johannesburg district in Gauteng
ART data. province and Mopani district in Limpopo province, were
analysed. Of the seven regions in Johannesburg, four
Despite the widespread availability of ART, there is still a (C, D, E and G) were included in the analysis, as these regions
considerable burden of HIV-related morbidity and mortality. have been supported by Anova Health Institute and routine
In South Africa, HIV accounted for almost two-thirds of data were therefore available for analysis. Johannesburg
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medical admissions at one hospital in 2012 and 2013, with no district has a population density of 3044 persons/km and is
improvement in the number of deaths due to AIDS nationally relatively economically affluent, falling into socio-economic
from 2013 to 2017, and in West Africa, AIDS-defining quintile 5. In contrast, Mopani district is sparsely populated
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conditions remained the primary cause of hospitalisation and socio-economically deprived, having a population
among HIV-infected adults years after the scale-up of ART density of 56.9 persons/km and a socio-economic quintile
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services. High morbidity and mortality is specifically of 2. Antenatal HIV prevalence, a proxy for overall
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associated with late presentation for HIV care, as indicated by population prevalence, is 29.6% and 24.5% in Johannesburg
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low baseline CD4 counts or advanced clinical stage. 3,16,17,18 and Mopani districts, respectively. Both districts provide
These poor outcomes potentially undermine the population- HIV care and treatment services, with 71.8% and 72.9% of
level impact of the ART programme, as ART coverage in adults diagnosed with HIV-infection being retained on ART
individuals is known to impact HIV transmission, incidence at 12 months, respectively. 21
and community viral load. 19,20 Interventions to improve ART
initiation, specifically among clients at risk of presenting late In April 2018, data for Johannesburg and Mopani districts
for HIV care, are therefore essential to improve both individual- were extracted from TIER.Net. Records were included in the
and programme-level outcomes. This study used operational analysis from clients initiating ART between 2004 and 2017
programme data to describe ART initiation and outcome (inclusive), where clients were 15–80 years of age, were newly
trends over time, with a focus on clients presenting late for initiating ART and had a baseline CD4 count on record. In
care, so as to identify programmatic gaps that can guide order to exclude outlying CD4 counts that were likely data
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interventions to reduce HIV-associated morbidity and errors, records with baseline counts above 2000 cells/mm
mortality. Two districts were investigated as examples of the were excluded. For the Kaplan–Meier analysis only, clients

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