#AIDS2010 presentations take closer look at ART Guidelines

The new WHO Guidelines on ART initiation (published in 2009) recommend a fundamental shift from the current policy of recruiting patients into treatment. The most crucial changes are the new threshold of 350 CD4 cells per mm3 for ART initiation; the ART 1st line regimens will also phase out Stavudine because of its toxicity. Additionally, ART recruitment will have to be determined more regularly through immunological tests than by using clinical criteria.

There are already concerns about the practicality of these new guidelines, considering that some resource-constrained countries (a fashionable periphrasis to indicate poor countries) have so far failed to entirely comply with the previous guidelines.

However, at this conference there were fascinating presentations on the costs and cost-effectiveness of introducing or expanding the use of CD4 count tests, adding the viral load determination to the range of tests available, and assessing which option could combine feasibility and cost-effectiveness. Incidentally, let us stress the fundamental point that cost-effective does not mean cheaper, but implies a better use of resources.

We heard that CD4 count is a better option than clinical judgment to recruit patients on ART, and it will also be more cost-effective if the price of a single test would drop below $4USD. But CD4 count is not equally effective in determining treatment failure and pushing for the switch to 2nd line regimen, which can still be managed using clinical guidelines and algorithms. Presenters all agree on the need to have CD4 count at the point of care; however, an interesting experience on measuring viral load from Argentina showed that using dried blood spots (DBS) – the same technique currently in use for early infant HIV diagnosis – and ferrying samples to a central laboratory could be an attractive option for many low-income countries, by minimizing problems of equipment, preservation and transport.

On the other hand, viral load determination did not seem to have convinced most scholars on its use and expansion. The technique is costly and complex, and its introduction has not shown either individual benefits (like prolonged survival of patients) or any cost-effectiveness.

Overall, viral load determination did not seem to have convinced most scholars on its usefulness and expansion in developing countries. The technique is costly, complex and its introduction has not shown either individual benefits (like prolonged survival of patients) or any cost-effectiveness.

What is the lesson learned from this new evidence? Probably, our programs will see more and more frequently the use of CD4 count tests, depending on various national policies and different degrees of compliance with the WHO guidelines. We need to be ready to incorporate this element into our activities that are related to HIV care and treatment. Additionally, we may look into possible alternative options to implement the provision of CD4 tests. In Uganda, for example, we explored an outsourced system of outreach services to replace the existing static laboratory centers, whose efficiency level at government facilities has been disappointing. This system proved helpful especially for the patients, who did not have funds associated with transport and for the health workers, whose clinical assessment was effectively assisted in selecting patients for ART initiation.

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