How can earlier entry of patients into antiretroviral programs in low-income countries be promoted?

Abstract

Sir—We read with interest the editorial by Colebunders et al. [1] concerning the ongoing challenges of providing antiretroviral treatment (ART) access for persons infected with HIV in Africa. At an antiretroviral service in Kampala, Uganda, a key issue highlighted by the authors was that the mean CD4 cell count at initiation of ART was just 63 cells/µL; the majority of patients presented to the service with advanced symptomatic disease. Late presentation is costly in terms of morbidity, mortality, and use of secondary health care resources and also limits the potential for restoration of immune function [2, 3]. In a community-based ART program in Gugulethu, South Africa, we have initiated treatment for >1000 patients over a period of 3 years, and yet the median CD4 cell count at enrollment has remained at <100 cells/µL. Early optimism that this measurement would increase once the backlog of patients with very advanced disease had received ART has not materialized here or in Kampala.