Persistent High Burden of Advanced HIV Disease Among Patients Seeking Care in South Africa’s National HIV Program: Data From a Nationwide Laboratory Cohort

The South African national HIV program has achieved substantial antiretroviral therapy (ART) coverage over the last decade, reaching 56 percent of all human immunodeficiency virus (HIV)– infected people in 2016. As ART scale-up continues, it is anticipated that increased access to treatment and reduced stigma will lead to treatment initiation earlier in HIV infection. Studies have shown that those who initiate ART at higher CD4 white blood cell counts when the disease is less severe can expect a near-normal life expectancy and are at dramatically reduced risk of HIV transmission.

Despite efforts to promote earlier treatment initiation, limited data is available on the existing burden of advanced HIV disease in South Africa and trends over time. Recent analysis of laboratory results suggests that the proportion of patients with advanced and very advanced HIV disease remains high.

In a new journal article published in Clinical Infectious Diseases, Jacob Bor and coauthors assess the distribution of patients in South Africa presenting with advanced and very advanced HIV disease, as indicated by a CD4 cell count, and identify changes in distribution patterns over the last 10 years. They construct a national HIV cohort using laboratory records from 2004-2016 to determine the timeline of patients’ entry into care. 

Main findings:

• From 2005-2016, the proportion of patients with advanced disease entering into care declined from 46.6 percent to 32.9 percent. However, from 2012-2016, the proportion of patients presenting with advanced HIV disease remained relatively unchanged. 
• The proportion of patients presenting with very advanced HIV disease fell from 27.7 percent in 2005 to 18.1 percent in 2011 but has remained unchanged over the last five years.
• Between 2005-2016, the proportion of males presenting with advanced disease was consistently higher than the proportion of females presenting with advanced disease. 

The findings are consistent with other data from both high-income settings and low- and middle-income settings which report a general increase in average CD4 cell count at presentation and at initiation of ART. These gains are due in part to changes in policies supporting earlier access to treatment and improvements in drug efficacy and tolerability as well as formulation. 

Nevertheless, there is a persistent population of patients who present late for care with advanced HIV disease. Furthermore, the sex disparities consistently increased over the study period, with the relative risk of males entering into care with advanced disease increasing in the later years. In addition to promoting earlier care-seeking, there is a continued need to identify patients with advanced HIV disease and to target this population with an appropriate package of care and services to address the high risk of morbidity and mortality they face.