CD4

The initial CD4 cell counts of patients newly infected with HIV fell significantly between 1985 and 2001, US research published in the May 1st edition of Clinical Infectious Diseases has shown. This suggests that the virus may have evolved to become more virulent during this time period, which could have clinical implications, shortening the interval between infection with HIV and the need to start HIV treatment. In people with HIV, CD4 cell counts provide an important indication of the strength of the immune system, of HIV disease progression and of when to start antiretroviral treatment.

Starting antiretroviral therapy earlier, before the development of symptoms, is the most likely way to reduce the high death rates after treatment initiation seen in people with HIV in resource-limited settings, two large cohort analyses show. The studies also show that the major disadvantage of starting treatment late an increased risk of death may persist for some years, burdening already overstretched health systems with illness that could be avoided by earlier treatment.

A single test that enables healthcare workers to obtain results for both the absolute CD4 count and CD4 percentage has been made available throughout Africa. It promises less demand on healthcare resources in countries desperately needing to implement more effective and rapid immune system testing for HIV-positive patients.

Voluntary counselling and testing (VCT) services are meant to help HIV-positive people cope with the disease, but some counsellors are doing more harm than good, particularly in KwaZulu-Natal.

Access to antiretroviral (ARV) treatment in South Africa's KwaZulu-Natal province is being hampered by long delays in tests required for HIV/AIDS monitoring.

Individuals who started highly active antiretroviral therapy (HAART) when their CD4 cell count was still reasonably strong and their viral load was below 70,000 copies/ml may be able to safely interrupt HIV therapy for a protracted period of time, according to a study published in the August 1st edition of Clinicial Infectious Diseases.

While saving the taxpayer more than 4.5 billion rands, Dr Debbie Glencross has developed a cost effective method for monitoring CD4 count in HIV/AIDS patients.

Despite much optimism, the training and resource shortcomings of rural hospitals and clinics may stymie antiretroviral rollout, writes Kerry Cullinan. People living with HIV/AIDS around the country are anxiously waiting to see whether Cabinet will approve an operational plan to introduce antiretroviral drugs into the public health sector. The immediate priority is to prepare health facilities and provide training for health workers - the vast majority of whom have had absolutely no training in antiretroviral treatment. While the detail of the operational plan has been a tightly guarded secret, insiders close to the task team say it proposes that each health district in the country should have a service point to deliver antiretroviral drugs. This means that initially there will be 56 service points countrywide. These will be centred at hospitals, but may also include the clinics that the selected hospital serves. Metropolitan areas, which each count as a health district, are likely to be permitted to have more than one service point. Initially, the task team had proposed that provinces should identify their own sites. However, the Department of Health apparently rejected this idea in favour of the district-based model, fearing a more ad hoc approach would be inequitable. According to the current proposal, doctors will be in charge of the plan. They will assess patients, prescribe the antiretroviral drugs and check on patients every three months. However, patients will be expected to come to their service centre every month, where nurses will check their progress and drug adherence. Before patients get their drugs, they will be expected to attend three treatment training sessions. These will explain how the drugs work and the common side effects and help patients to work out a treatment plan that will ensure they take the drugs every day at the same time. Under-serviced rural hospitals pose a particularly tough challenge, as Dr Paul Pronyk, director of Wits University's Rural AIDS and Development Action Research Programme, based in rural Limpopo, knows only too well. He sees the chronic lack of health resources every day, and says, a systematic and cautious approach is necessary for the roll-out of antiretrovirals at Limpopo hospitals. The antiretroviral roll-out is not simply about administering drugs, says Pronyk. Hospital laboratories don't work. Health workers need to be trained. Proper patient registers need to be kept. Patients need counselling. The drug supply must be safe and secure, because there will be a public health disaster if they get into the black market. Nevertheless, Pronyk believes that universal access to antiretrovirals is possible - but only if there is full buy-in by government, which results in large-scale capacity building. He points out that there are massive funds available for the antiretroviral rollout, both from the South African government and international donors. One thing that has lightened the government's load in recent weeks has been the dramatic lowering of antiretroviral prices. Last week the Clinton Foundation announced that it had brokered a deal with generic manufacturers, including the Johannesburg-based company Aspen Pharmacare, that would reduce the price of triple therapy to about R81 per patient a month for public-sector buyers. This is less than half the previous best price available. The TAC has described this huge reduction as excellent progress, although it is concerned that some of the generic manufacturers have not been licensed by patent holders to produce generic versions of their drugs. This means that they could infringe patents if they do produce the drugs. In addition, the Medicines Control Council has not yet licensed some of the generic antiretrovirals that have been given the go-ahead by patent holders. It may take a little while to sort out these complications, but the massive price reduction makes antiretroviral intervention far more affordable as a life-long treatment option. But prevention is still the best medicine, and the Department of Health is concerned that the antiretroviral treatment rollout must go hand-in-hand with prevention. While there are no miracle cures, British medical journal the Lancet published a study a few weeks ago demonstrating that antiretroviral treatment could buy patients at least 10 more years of life. The thought of spending 10 more productive years with the people they love is a powerful message of hope for the 4.5-million South Africans living with HIV/AIDS. - Health-e News Service. (Source: Kerry Cullinan: The Sunday Times, 2 November 2003) Link //\// Determinants of survival following HIV-1 seroconversion after the introduction of HAART http://www.thelancet.com/journal/vol362/iss9392/full/llan.362.9392.origi...

Scientists have come up with a faster and cheaper HIV/AIDS monitoring technique which could make treatment more affordable in developing countries. A study conducted by researchers in Zambia's University Teaching Hospital and the University College in London, has found that spots of dried blood, filter paper and inexpensive commercially available chemicals, could be developed into a field-friendly alternative to the sophisticated technology required to carry out CD4 count testing. A CD4 count measures the strength of the immune system. Although ARVs are increasingly becoming available in African countries at reduced prices, the high cost of monitoring equipment remains one of the biggest obstacles. Researchers at the University Teaching Hospital took blood spots from 42 HIV-positive patients and put them on filter paper, which was allowed to dry. The test samples were then sent to a central clinic without refrigeration. The blood spots were analysed using a simple test involving antibodies that latched onto CD4 cells. The bound antibodies caused a colour change in a solution made from the dried blood: a deeper colour equaled a higher cell count. The report found that filter papers offered an attractive alternative to use of fresh whole blood. Once the samples have dried, the filter papers can be stored at room temperatures for long periods before being batched and sent to a central laboratory. The results compared very well to the [flow] cytometer - there were some very slight variations but these won't change the meaning of the result, Mwaba noted. Mwaba called for African scientists to take such work forward and come up with innovative ways to provide such technology. ( Source: IRIN, PLUSNEWS 4 November, 2003) Link //\// Use of dried whole blood spots to measure CD4+ lymphocyte counts in HIV-1-infected patients http://www.thelancet.com/journal/vol362/iss9394/full/llan.362.9394.origi...

According to research presented as a poster to the Seventh ICAAC in Chicago on September 15th, individuals may be able to interrupt HAART if they have a high nadir CD4 cell count, lost CD4 cells slowly before starting anti-HIV therapy, and have maintained an undetectable viral load for at least a year whilst taking HAART. Data presented this week at the 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) suggested that patients whose nadir CD4 cell count was above 350 cells/mm3 and had achieved an undetectable viral load for at least a year whilst sustaining a CD4 cell count of over 800 cells/mm3, could safely interrupt HAART for a prolonged period. Investigators conducted a multi-centre, observational, retrospective study involving 140 patients from several treatment centres in Italy, Sweden and the UK. To be included in the analysis, a patient must have taken HAART for at least twelve months, have a nadir CD4 cell count above 250 cells/mm3, a pre-treatment interruption CD4 cell count of at least 500 cells/mm3, and to have taken a break from HIV therapy for at least four weeks. HAART was restarted if a patient’s CD4 cell count fell below 350 cells/mm3 or if they expressed a wish to recommence treatment. Median CD4 cell count when the study patients initially started HAART was 410 cells/mm3, and median viral load was 26,000 copies/mL. The study participants had been infected with HIV for an average of three and a half years. At the point of treatment interruption, median CD4 cell count was 804 cells/mm3 and median viral load was 50 copies/mL. As of April 1st 2003, 53% of patients were still off-therapy, 24.3% had experienced a drop in their CD4 cell count to below 350 cells/mm3 and 22% had restarted HAART. The median duration of the treatment interruption at this point was 104 weeks. Investigators established that independent predictors of having to restart therapy were lowest ever CD4 cell count, duration f an undetectable HIV viral load whilst on HAART, the rate with which CD4 cell count declined before HAART was initially started, and HIV viral load immediately before the treatment break was commenced. An individual can interrupt HAART for a long-time, the investigators conclude, if their CD4 cell count never dropped below 350 cells/mm3 prior to first commencing anti-HIV therapy, HAART achieved a viral load below 50 copies/mL for at least twelve months, their CD4 cell count fell slowly before HAART was initiated, and during the treatment break HIV viral load only rebounds to low levels. Reference: Mussini C et al. CD4-guided treatment interruptions: a new therapeutic strategy. 43rd ICAAC, abstract H-856, Chicago 14 -17th September, 2003. (Source:AIDSMAP, 16 September 2003) http://www.aidsmap.com/news/newsdisplay2.asp?newsId=2288