Share this article on:

Initiating highly active antiretroviral therapy in sub-Saharan Africa: an assessment of the revised World Health Organization scaling-up guidelines

Badri, Motasim; Bekker, Linda-Gail; Orrell, Catherine; Pitt, Jennifer; Cilliers, François; Wood, Robin

Clinical Science

Objectives: To assess the utility of the 2003 revised World Health Organization (WHO) criteria [initiating highly active antiretroviral therapy (HAART) in stage IV, in stage III plus CD4 cell count < 350 × 106 cells/l, or in stage I or II plus CD4 cell count < 200 × 106 cells/l] relative to other scenarios of HAART initiation.

Methods: Progression to AIDS and death in 292 patients taking HAART and 974 not taking HAART in a South African institution in 1992–2001, stratifying patients by baseline CD4 cell count and WHO stage.

Results: HAART was associated with decreased AIDS [adjusted rate ratio [ARR], 0.16; 95% confidence interval (CI), 0.08–0.31) and death (ARR, 0.10; 95% CI, 0.06–0.18). Benefit of HAART was significant across all WHO stages plus CD4 cell counts. The greatest number of deaths averted was in stages IV [74.0/100 patient-years (PY); 95% CI, 50.2–84.5) and III (32.8/100 PY; 95% CI, 22.4–40.9). AIDS cases averted in stage III (22.0/100 PY; 95% CI, 6.1–26.9) were higher than in stage I and II with CD4 cell count < 200 × 106 cells/l (8.9/100 PY 95% CI, 5.6–13.3). Treatment initiation for symptomatic disease resulted in greater benefits than using any CD4 cell thresholds. Application of WHO criteria increased the treatment-eligible proportion from 44.5% to 56.7% (P < 0.05) but did not prevent more death (P > 0.05) than treating symptomatic disease.

Conclusion: Implementation of the revised WHO guidelines in sub-Saharan Africa may result in a significantly increased number of individuals eligible for treatment but would not be as effective a strategy for preventing death as treating symptomatic disease.

From the Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, University of Cape Town, South Africa.

Correspondence to Professor Robin Wood, Desmond Tutu HIV Centre, Werner Beit North Building, Ground Floor Medical School, University of Cape Town, Anzio Rd, Observatory 7925. South Africa.

Received: 18 December 2003; revised: 6 February 2004; accepted: 17 February 2004.

© 2004 Lippincott Williams & Wilkins, Inc.