While government grapples with how to accommodate new World Health Organisation (WHO) guidelines on HIV treatment, which mean over a million extra people are immediately eligible for antiretroviral medicine, a leading AIDS expert has warned that these may be a "distraction".
The WHO recommended last month that people with a CD4 count of 500 or less should be put on antiretroviral medicine. It also recommended ARVs for all pregnant and breastfeeding women, all children under the age of five, people with tuberculosis or hepatitis B and people with HIV-negative sexual partners.
But Professor Francois Venter says treating all people with CD4 counts of 500 and below, instead of the current CD4 of 350 "is not a priority but a distraction" as most HIV transmission is from people with CD4 counts below 350.
"We need to fix the system and get the core treatment programme right for people with CD4 counts of 350 and less," says Venter, Deputy Director of the Wits University's Reproductive Health and HIV Institute.
A CD4 count is the measure of white blood cells per cubic millimetre of blood in a person's body, with 500 being at the low end of the normal range. The virus attacks the white blood cells first, so a person's CD4 count gives a good idea of how far the virus has progressed.
"The WHO guidelines presuppose a strong health system, but we have been seeing drug stock-outs and some ARVs in short supply being substituted with others."
Venter is also concerned of the build-up of toxicity in patients who are put onto the early HIV medicines, such as stavudine, for a longer period.
The Department of Health has accepted the WHO's proposals, and spokesperson Joe Maila says they are considering ways to implement them.
At present, South Africans with CD4 counts of 350 or less, all pregnant women and children under five are all eligible for ARVs. Government is also poised to recommend ARV treatment for all those co-infected with TB.
"There is a huge benefit for people with HIV negative partners to be on ARVs from earlier on, but the health benefits of treating everyone from CD4 of 500 are based on poor data," says Venter.
"Most HIV transmission is from people with CD4 counts of under 350. For example, about 85 percent of mother-to-child transmission of HIV is when the mother's CD4 count is below 350," says Venter.
"If we treat everyone from CD4 350, we will get most of the transmission prevention benefits as if we treat all those from CD4 500."