Advanced HIV Disease / AIDS Technical Summary for Activists Gilles Van Cutsem, SAMU, MSF
Objectives Why is increased investment in Advanced HIV Disease (AHD) / AIDS critical? What are the issues? What are we asking for?
Definition of advanced disease Adults, adolescents and children 5 years with: CD4 cell count < 200 or WHO stage 3 or 4 event All children <5 years old with HIV infection
Why we need to invest in AHD/AIDS 940 000 HIV deaths in 2017 (WHO GHO, 2018) Decline in HIV deaths is slowing down (WHO, 2018) 1/3 PLHIV present to care with AHD (WHO, 2017) Majority of PLHIV admitted to hospital have AHD (Ousley 2018, CID) Inpatient mortality is extremely high (Ousley 2018, CID) HIV response has focused on Test & Treat Neglect of mortality reduction (e.g. PEPFAR only introduced an indicator on mortality in 2018)
Role of ART experienced underestimated Historical focus on T&T of late presenters Shift of AHD towards ART experienced: Re-entry into care after treatment interruption Undetected or untreated treatment failure Most important factor for future adult HIV incidence: viral suppression on ART (Johnson 2016, GHA)
Late presentation & ART discontinuation 2016 South Africa 33% started ART at CD4 <200 17% started ART at CD4 <100 Men twice as likely to start late Carmona et al Clin Inf Dis 2018; Osler et al; Clin Inf Dis 2018 Continuing Burden of Advanced HIV Disease Over 10 Years of Increasing Antiretroviral Therapy Coverage in South Africa,Meg Osler & all, CID 2018;66,suppl 2)
Factors influencing future HIV incidence (Johnson 2016)
ART failure & ART interruption Opportunistic infections: 1. TB 2. Cryptococcal Meningitis 3. Severe Bacterial Infections 4. Pneumocystis Pneumonia (PCP) 5. Toxoplasmosis 6. Kaposi Sarcoma (Ford 2015, Lancet) Main causes of death
What do we need AHD in national policies Diagnostic & screening tests: CD4 VL CrAg TB-LAM GeneXpert Prevention: TB: CTX/INH/B6; 3(1)HP; IPT Crypto: fluconazole Toxo, PCP & SBI: cotrimoxazole (CTX) Treatment: Crypto: flucytosine, amphotericin B, fluconazole Toxo/PCP: CTX, clindamycin, primaquine SBI: broad-spectrum antibiotics (ceftriaxone ) Kaposi: chemotherapy (PLD, ABV, paclitaxel) Models of care: Adherence strategies Early Tracing of lost to follow-up Welcome back services Post-discharge follow-up
Policies: preliminary results from the dashboard Kenya, Lesotho, Zambia have AHD policies Other 29 countries surveyed don t
CD4 The entry door to the AHD package of care NOT for monitoring (unless there is no VL): targeted or diagnostic CD4 For diagnosis of AHD: At initiation or re-initiation of ART If VL is high If clinically indicated (e.g. new OI) To help with diagnosis of Ois (frequency differs at different CD4) In Emergency Wards POC is preferable Gap: Often not funded by PEPFAR, GF, MoH Stockouts of reagents and cartridges Maintenance of machines
Viral load At 6 months after start ART and then annually Essential to detect poor adherence or treatment failure Needs to lead to re-suppression Number switched to 2 nd line Gaps: Often only # of 1 st VL reported Useless without # 2 nd VL and # switched to 2 nd line Report on % on ART who are suppressed Commodities often not present Laboratory capacity
TB-LAM Greatly increases detection of TB Decreases mortality in hospital (STAMP trial) Shortens time to TB treatment (Huerga 2018) For all PLHIV admitted to hospital + at PHC all with TB symptoms or severely ill Role for screening unclear Gaps: Hardly used outside of research (except South Africa) Very limited provision by PEPFAR and GF Often no policy
CrAg For all CD4<100 Positivity should lead to lumbar puncture At hospital and PHC Gaps: Policy Funding Supply
Treatment TB: - CTX/INH/B6-3HP Crypto: - Fluconazole: funding, supply - Flucytosine: registration, policy, funding - Ampho B: funding, adverse events - Liposomal Ampho B: policy, cost
Treatment Severe bacterial infections: Antibiotics: ceftriaxone Kaposi sarcoma: The key is to have some chemotherapy options: PLD (pegylated liposomal doxorubicin): best but expensive and production issues Paclitaxel: cheaper but slightly more complex ABV (doxorubicin/bleomycin/vincristine): inferior to options above but cheaper; definitely better than nothing. Mono- and bitherapy are last resort, inferior options
Models of care Adherence support & differentiated models of care to help patients stay on ART Early tracing of lost to follow up: to bring patients with AHD back into care Welcome back services: to ensure people with prior ART exposure feel comfortable and access adequate treatment Post-discharge follow-up: to prevent high mortality after hospitalisation