Page 228 - HIVMED_v21_i1.indb

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 11 Review Article

The evolution and adoption of World Health Organization

policy guidelines on antiretroviral therapy initiation in

sub-Saharan Africa: A scoping review

Authors: Background: Despite past and present global interventions, the human immunodeficiency
Sabina M. Govere 1 virus (HIV) pandemic remains a public health problem in low- and middle-income countries
Moses J. Chimbari 1
(LMICs). The World Health Organization (WHO) has assisted these countries by providing
Affiliations: antiretroviral therapy (ART) policies for adoption and adaptation to local needs.
1 College of Health Sciences,
University of KwaZulu-Natal, Objectives: This article describes the response of countries in sub-Saharan Africa (SSA), to the
Durban, South Africa WHO’s changing CD4-threshold ART-initiation recommendations of the past two decades.
Corresponding author: Methods: Relevant articles published in international peer-reviewed journals were accessed
Sabina Govere, via the following search engines: PubMed, Google Scholar, Cochrane, Embase and EBSCOhost.
[email protected]
The study’s inclusion criteria were articles published in the English language between 2000
Dates: and 2019 that highlighted changes to the CD4 ART-initiation threshold and that focused on the
Received: 06 May 2020 WHO’s ‘commencement of ART’ policy guidelines. Sixteen studies (n = 16) from SSA were
Accepted: 26 July 2020 identified and included in this review: four are cross-sectional, four deal with cost-effectiveness,
Published: 30 Sept. 2020
four are retrospective, one is a randomised trial and three are observational studies. Only
How to cite this article: studies conducted in SSA were assessed.
Govere SM, Chimbari MJ. Results: Four themes emerged: (1) adoption of the WHO CD4-ART-initiation policy by SSA
The evolution and adoption
of World Health Organization countries, (2) timely implementation of the changing guideline initiation policy in the region,
policy guidelines on (3) barriers and facilitators encountered in the implementation of the changing guidelines
antiretroviral therapy initiation and (4) description of similarities in policy implementation at country level from 2002 to
in sub-Saharan Africa: A 2019. Regional studies – cross-sectional, observational, retrospective, cost-effectiveness and
scoping review. S Afr J HIV
Med. 2020;21(1), a1103. randomised have described greater access to ART in SSA. However, barriers remain. The
https://doi.org/10.4102/ most common barriers to the timely implementation of ‘new’ ART-initiation guidelines were
sajhivmed.v21i1.1103 economic constraints, drug stock-outs, delays in obtaining baseline blood-test results and
Copyright: staff shortages.
© 2020. The Authors. Conclusion: Although countries in SSA have adopted the WHO-ART-CD4 initiation-threshold
Licensee: AOSIS. This work
is licensed under the policy guidelines, implementation has seldom occurred in a timely manner. Barriers have been
Creative Commons identified. Whilst a small number of countries have implemented recommendations promptly,
Attribution License. for many, the barriers still require to be overcome.

Keywords: ART initiation; WHO-ART guidelines adoption; implementation of ART guidelines
in sub-Saharan Africa; CD4; human immunodeficiency virus.

Background

The first cases of the acquired immunodeficiency syndrome (AIDS) were reported in 1981. Since
then, infection with human immunodeficiency virus (HIV) has spread globally and caused an
estimated 74.9 million infections and 32 million AIDS-related illnesses. In its first 15 years no
1
treatment could control the infection or halt its spread. By 2018, the African region was home to
2
approximately 25.7 million people living with HIV (PLWH) and in that year alone, Africa
1
experienced approximately 1.1 million new infections. Almost two-thirds of all new global
1
infections occur in sub-Saharan Africa (SSA). 1
The World Health Organization’s (WHO’s) antiretroviral therapy (ART) initiation-guidelines
Read online: have changed substantially over the last two decades. The guidelines were first published in
2
Read online:
Scan this QR 2002. These (2002/2003) recommended starting ART in those with AIDS-related conditions
Scan this QR
3
code with your
code with your
smart phone or
smart phone or and/or at a CD4 of ≤ 200 cells/mm. The available treatment at that time was expensive and toxic.
mobile device Delaying ART until the CD4 reached levels < 200 c/mm was intended to minimise these
mobile device
3
to read online.
to read online.
4
drawbacks. Continued deaths from AIDS and success with ART prompted a CD4 increase in 2006
http://www.sajhivmed.org.za 220 Open Access