Selecting patients for antiretroviral therapy

Patient selection is one of the more difficult aspects of setting up a programme, as the need inevitably outstrips the supply of drugs available. However, it is important to note that, contrary to popular perception, not all people with HIV should immediately be placed on antiretroviral therapy. In Khayelitsha, the biological and clinical criteria used to select patients include:
  • a CD4 T cell count of less than 200, and a WHO disease stage of 3 or 4, both in line with WHO's recently-released guidelines on antiretroviral therapy in resource-poor settings;
  • patients must live in Khayelitsha;
  • patients must have regularly attended the clinics for at least three months (instituted in light of the highly mobile nature of Khayelitsha's population). These requirements plus the fact that some patients chose not to take antiretroviral therapy mean that the number of patients who were ultimately candidates to be started on therapy has not overwhelmed the resources available. Nonetheless, a system was introduced that involved the community in the process of selecting patients. A number of community representatives - typically people with experience with people with HIV (and including those with HIV themselves) - met regularly to assess candidates and determine who would ultimately be placed on therapy. Deliberations are based on a number of factors, such as the health of the patient, their income level, the social support available to the patient and her/ his openness about HIV infection, and if other members of the same family are already on antiretroviral therapy. Although the process is time-consuming, it has proven a valuable way to fairly and equitably allot spots in the treatment programme, as well as an important means of ensuring community ownership over the programme.