South Africa updates HIV treatment guidelines

Keith Alcorn
Published: 29 March 2010

South Africa’s National AIDS Council has published updated HIV treatment guidelines that will reduce the use of stavudine (d4T), promote earlier treatment for pregnant women and people with both HIV and TB, and improve the regimen used to prevent vertical transmission in pregnant women.

The new guidelines adopt some of the recent recommendations made by the World Health Organization (WHO), most notably phasing out the use of stavudine.

Activists and doctors in South Africa have been campaigning for several years to drop stavudine from first-line treatment because of the side-effects of the drug, which include peripheral nerve damage (neuropathy), fat loss in the limbs and face (lipoatrophy) and life-threatening increases in lactate levels (hyperlactataemia and lactic acidodis).

The new guidelines recommend that all patients starting treatment for the first-time should receive a combination of tenofovir and 3TC or FTC, with either nevirapine or efavirenz.

People currently taking d4T should switch to tenofovir if they show any of the side-effects associated with the drug, or if they are at high risk for side effects (higher body mass index, low haemoglobin or older female).

However, the guidelines do not adopt all the recent WHO recommendations, which included the recommendation that people should start treatment when their CD4 count falls below 350 wherever possible.

South Africa continues to recommend that most people should start treatment when their CD4 count falls below 200 cells/mm3, but the new guidelines recommend earlier treatment for four groups:

  • Anyone with WHO stage 4 HIV disease (opportunistic infections) regardless of CD4 count
  • People with HIV diagnosed with TB with a CD4 count below 350
  • Pregnant women with a CD4 count below 350
  • Anyone with multi-drug resistant (MDR) or extensively drug-resistant (XDR) TB.

Pregnant women eligible for ART, anyone with an opportunistic infection, anyone with a CD4 count below 100 and anyone with MDR or XDR TB will be `fast-tracked` for antiretroviral treatment, meaning that they should start treatment within two weeks of diagnosis.

Pregnant women not eligible for immediate ART will receive antiretroviral prophylaxis with AZT from week 14 of pregnancy onwards, single-dose nevirapine at the onset of labour and a single dose of tenofovir and FTC after delivery.

Infants will receive nevirapine prophylaxis throughout the breastfeeding period, or for six weeks after delivery if formula-fed.

Infant treatment guidelines have also been updated. All children with HIV of one year and under will be treated, as will children aged one to five with a CD4 percentage below 25 or a CD4 count below 750. All infants and children below the age of three will receive abacavir, 3TC and lopinavir/ritonavir, while older children will receive efavirenz instead of lopinavir/ritonavir.

The guidelines are designed to allow treatment to be initiated and monitored by nurses, and treatment provision will be expanded from accredited ART centres to primary health care clinics. The accompanying HIV testing drive will incorporate TB screening measures.