Times Of Swaziland: Swazis in new HIV treatment trials

Swazis in new HIV treatment trials
================================================================================
BY MDUDUZI MAGAGULA on 12/05/2013 13:54:00


MBABANE - Swaziland, with the world’s highest incidence of HIV, is embarking
on pilot projects to offer treatment to all people who are HIV-positive,
irrespective of their CD4 count.
The studies will investigate if the use of ‘treatment for prevention’ could
reduce new HIV infections among Swa-zis. The new approach is called ‘Treat
All.’ Three implementation studies will be taking place this year in three
different settings. Government and non-governmental organisations (NGOs) are
involved.
The Treat All programme involves treating everyone who is HIV-positive,
irrespective of their viral load, CD4 count, or disease stage, with the aim of
maximising health benefits and preventing the spread of HIV.
CD4 (cluster of differentiation four) is a glycoprotein found on the surface of
immune cells such as T helper cells, monocytes, macrophages, and dendritic
cells.
CD4 cells are used as a measure for a persons’ strength of immunity.
In February, Doctors without Borders (MSF) began offering anti- retrovial
treatment (ART) to all HIV-positive pregnant women regardless of their CD4 count
in the Nhlangano health zone, an approach known as Option B+.
Later this year, another Option B+ pilot will be implemented by the
International Centre for AIDS Care and Treatment Programmes (ICAP).
This study will take place in selected clinics within the Manzini region.
Towards the end of 2013, the Clinton Health Access Initiative (CHAI) plans to
offer ART to all HIV-positive adults at selected facilities in the Hhohho
region. If the pilot projects are successful and the treatment as prevention is
adopted as policy in the country there will be between 200 000 and 240 000
people who will be enrolled for the  treatment. These are people who are already
living with the virus.
Velephi Okello, National Coordinator for Swaziland’s Antiretroviral Therapy
programme under the Ministry of Health, said the ‘Treat All approach’ was
more effective in terms of improving people’s health and reducing the
transmission of HIV. However, current treatment guidelines, as stipulated by the
World Health Organisation (WHO) in its 2010 protocol for treatment, state that
treatment should be initiated when one’s CD4 count is 350 and less.
Okello said all these studies had been guided by her ministry and they would
span for a period of three years.
She said the ministry would look into the findings of these studies to assist in
making a policy decision on whether to roll out the treatment as a prevention
approach.
Okello said the adoption of the ‘treatment as prevention’ approach was
dependant on the success of the studies that were being undertaken by the
organisations.
“The studies would help us to understand the cost effectiveness of
implementing treatment as prevention for pregnant women and for the nation as a
whole,” she said.
Using treatment to prevent HIV transmission has been studied for many years but
the turning point came with the August 2011 publication by Myron Cohen and
colleagues which showed a 96 per cent reduction in risk of HIV transmission in
sero-discordant (one partner positive, the other negative) couples in which the
HIV positive partner was taking ARVs.
This clinical trial examined the extent to which antiretroviral therapy (ART)
can, when taken by people who have HIV, decrease their infectivity and thereby
reduce the chance that they will pass HIV onto their heterosexual partners.
Benedict Xaba, Minister of Health, told the Lancet, a medical magazine, that
eliminating mother-to-child transmission of HIV by 2015 was a priority in order
to ensure an HIV-free generation. He said Swaziland currently used option A of
the two WHO-endorsed protocols for prevention of mother-to-child transmission
(PMTCT).
With option A, pregnant women with a CD4 count below 350 receive ART while the
baby gets a daily Nevirapine syrup for six weeks.
Women with a count above 350 receive prophylaxis Azidothymidine (AZT) during
pregnancy and for a week after birth - plus a Nevirapine injection at birth,
while the child gets Nevirapine daily for 18 months (throughout breastfeeding).
In Options B and B+, all HIV positive women receive ART regardless of their CD4
count, and will either stop at delivery or continue ART for the rest of their
lives. In some respects, Swaziland has had reasonable success with Option A. 
Coverage is excellent: 97 per cent of women attend at least one antenatal care
appointment and 91 per cent of those accept HIV testing.  In 2011, 86 per cent
of HIV-positive pregnant women received either ART or AZT prophylaxis.  At six
weeks of age, only four per cent of infants tested were found to be HIV
positive.
“But after birth, things deteriorate”, the Lancet magazine quoted Kiran
Jobanputra, MSF’s principal investigator in its Treatment for Prevention
Research Programme.
The total proportion of infants of HIV positive mothers who tested positive in
2011 was 17 per cent. This could suggest significant rates of HIV transmission
during brea-stfeeding.”
This situation may be because babies are not getting their Nevirapine syrup
after mothers return to work.