Key finding: More than a fifth (22 %) of the HIV-positive educator population would need antiretroviral therapy if health care providers use the national criteria based on WHO?s conservative guidelines for the initiation of antiretroviral therapy (ART). This is a CD4 count of less than 200 cells per mm? of blood (<200 cells/mm?). This would suggest that at least 2.8 % of all educators are eligible for immediate ART ? 10 000 of the 356 749 educators in public schools. Following the US Department of Health and Human Services’ (DHHS) guideline of a CD4 cell count of =350cells/mm? to initiate ART would increase the proportion of HIV-positive educators to more than 23 500.

Background

HIV-prevalence results tell us how many educators are living with HIV infection. What HIV prevalence data do not tell us is the proportion of HIV-positive educators in the later stages of HIV infection and at risk of progression to AIDS. To establish this, it is important to also measure the CD4+ T-lymphocytes (CD4 cells) ? a vital component of our immune system and a prime target of HIV infection ? of educators who provided blood specimens and were HIV-positive during the study.

Measurements of CD4 cell levels are used to assess the severity of HIV infection and to make decisions as to when to initiate antiretroviral therapy (ART). This data can provide essential information for estimating current and future levels of morbidity as well as for planning of treatment needs.

The selection criteria for when to start ART differs: the WHO’s selection criteria for commencing ART, which was adopted by the South African Government, is a CD4 count of less than 200 cells per mm? of blood (<200 cells/mm?). The US Department of Health and Human Services’ (DHHS) recommends that ARV therapy in asymptomatic patients should commence before the CD4 cell count declines to 200, or equals 350 cells per mm? unit of blood (=350 cells/mm?).

Methods

Usable blood or oral fluid specimens were obtained from 17 345 educators. CD4 cell counts were performed on HIV positive blood specimens. A significant number of the CD4 results had been rendered unusable, either due to delays during transportation and/or laboratory planning, or because of sample disintegration caused by poor temperature maintenance and/or poor specimen handling.

Eventually 444 valid samples out of 1 095 (41% of the total) could be analysed for CD4 cell count. The results of the CD4 cell count analysis in the HIV-positive educator study population are shown in Table 1.

Table 1: CD4 cell count profile in HIV-positive educators

Table 2 presents the proportion of CD4 cell counts in the categories <200, 200?350, and <=350 cells/mm3. The data indicate that 22% of the HIV-positive educators had CD4 cell count values <200 cells/mm3 and would be eligible for ART under national and WHO criteria for initiating antiretroviral therapy. Applying the guidelines of the US Department of Health and Human services, which call for offering treatment to asymptomatic patients with a CD4 cell count of <=350 cells/mm?, would increase the proportion of HIV-positive educators eligible for ART to 52%.

Table 2: Proportion of HIV-positive educators eligible for ART

Discussion

Our results suggest that more than a fifth (22%) of the HIV-positive educator population would need antiretroviral therapy, even if health care providers use the national criteria based on WHO?s conservative guidelines for the initiation of ART. Applying these findings to the total educator population of South Africa would suggest that at least 2.8 % (10 000 out of a total of 356 749) of all educators are eligible for antiretroviral therapy.

Taking a CD4 cell count of =350 cells/mm? as the level for the initiation of ART, as recommended by the guidelines of the DHHS, would increase the proportion of HIV-positive educators eligible for ART to more than 23 500.

Considerations of initiating ART are primarily based on the prognosis of disease-free survival, and starting ART at an earlier stage of infection would also reduce the incidence of opportunistic infections in HIV/AIDS patients.

Recommendations

Educators with a CD4 count of between >200-=350cells/mm? may also be advised by their health care providers to start antiretroviral therapy. These patients will not be able to access ART through the Government health services and would either have to use their medical aids or pay out of their own pocket.

The findings of this study are reason enough for the Department of Education to consider urgent measures to develop a targeted intervention, which would provide antiretroviral therapy and treatment of opportunistic infection for HIV-positive educators.

This is possible for several reasons:

• An estimated 67.8% of educators have medical aid.

• About 75% of educators visited a health practitioner in the last six months, suggesting that a programme involving health care providers, who already provide care to this captive audience, is feasible.

• The majority of HIV-positive educators (95%) say they will be prepared to use the government?s ART programme.

As long as demand for antiretroviral therapy is exceeding the available supply of treatment, a phasing in of ART programmes will be necessary. The study recommends that the Department of Education should consider a comprehensive programme consisting of prevention, treatment of opportunistic infections and antiretroviral therapy by district level. The study suggests that educators in the 11 districts with the highest HIV prevalence (>20%) should be targeted first.

The programme could then be extended to the next set of districts with HIV prevalence levels between 10% and 20%, and finally, focus on the districts with an under 10% HIV prevalence rate.

This staged process is critical to ensure that service provision is manageable. This recommendation is extremely urgent in the light of the fact that many of these educators are likely to fall sick and would not be able to continue to teach.