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

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)

Carmona et al Clin Inf Dis 2018; Osler et al; Clin Inf Dis 2018

Factors influencing future HIV incidence (Johnson 2016)

Main causes of death• ART failure & ART

interruption• Opportunistic infections:

1. TB2. Cryptococcal Meningitis3. Severe Bacterial

Infections4. Pneumocystis

Pneumonia (PCP)5. Toxoplasmosis6. Kaposi Sarcoma(Ford 2015, Lancet)

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 2nd line• Gaps: – Often only # of 1st VL reported– Useless without # 2nd VL and # switched to 2nd 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- 3HPCrypto: - 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