The WHO guidelines state emphatically that “treatment of patients with WHO clinical stage 4 disease should not depend on a CD4 cell count determination; all such patients should initiate ART” (WHO, 2006c, p. 14). In several of the sites visited by the Committee, symptomatic stage 4 patients were required to await a CD4 cell count before initiation of treatment, a sometimes lethal delay. Since CD4 cell count determinations are not available in the majority of treatment sites, PEPFAR can effectively address this issue by supporting countries in ensuring that medical and paramedical personnel at ART sites understand that no CD4 cell count is needed prior to initiation of ART in people with WHO clinical stage 4 and symptomatic clinical stage 3 disease.
A practice observed in a few treatment sites was a rigid requirement for a fixed number of readiness or adherence training sessions. Such practices are problematic in areas in which patients must travel long distances and/or have no means of transportation to treatment sites, and thus can pose an insurmountable burden, especially for people with advanced AIDS. PEPFAR can address this problem by supporting treatment sites in building reasonable flexibility into such preparatory programs.
Although results from the current limited surveillance will be helpful in determining the loci for more extensive resistance testing, the Coordinator has determined that it is now time to establish a more effective, systematic means of resistance monitoring in carefully selected sentinel populations more broadly representative of the focus countries. Both the high cost and the requirement for relatively sophisticated laboratory equipment make it impractical to establish widespread resistance testing at all treatment sites. The Committee supports PEPFAR’s plans to address the problem by establishing sentinel systems that monitor specific representative populations on a continuing basis to determine what resistance mutations are emerging and how rapidly, and by supporting the development of simple, inexpensive techniques for resistance monitoring with the potential for utilization at secondary and tertiary treatment sites.