Managing Advanced HIV Disease in a Public Health Approach

Abstract

In 2017, the World Health Organization (WHO) published guidelines for the management of advanced human immunodeficiency virus (HIV) disease within a public health approach. Recent data suggest that more than a third of people starting antiretroviral therapy (ART) do so with advanced HIV disease, and an increasing number of patients re-present to care at an advanced stage of HIV disease following a period of disengagement from care. These guidelines recommend a standardized package of care for adults, adolescents, and children, based on the leading causes of morbidity and mortality: tuberculosis, severe bacterial infections, cryptococcal meningitis, toxoplasmosis, and Pneumocystis jirovecii pneumonia. A package of targeted interventions to reduce mortality and morbidity was recommended, based on results of 2 recent randomized trials that both showed a mortality reduction associated with delivery of a simplified intervention package. Taking these results and existing recommendations into consideration, WHO recommends that a package of care be offered to those presenting with advanced HIV disease; depending on age and CD4 cell count, the package may include opportunistic infection screening and prophylaxis, including fluconazole preemptive therapy for those who are cryptococcal antigen positive and without evidence of meningitis. Rapid ART initiation and intensified adherence interventions should also be proposed to everyone presenting with advanced HIV disease.

Who is seeking antiretroviral treatment for HIV now? Characteristics of patients presenting in Kenya and South Africa in 2017‐2018

“…We acknowledge that the populations accessing care before and after UTT population are not exactly comparable, because some patients in the “before” population who believed themselves to have high CD4 counts, and thus ineligible for ART, may not have sought clinical care. That said, advanced disease at presentation remains an important challenge, with costs in terms of patient prognosis, HIV transmission risk and healthcare expenditure .…”

Proportions of CD4 test results indicating advanced HIV disease remain consistently high at primary health care facilities across four high HIV burden countries

“…Patients with advanced HIV disease, however, can have one of a number of other opportunistic infections, including pneumocystis pneumonia, etc. [10][11][12][13][14]. Most of these diseases can be prevented through prophylaxis or treated.…”

“…Most of these diseases can be prevented through prophylaxis or treated. Therefore, rapid and early identification of patients with advanced HIV disease, primarily through CD4 testing, in order to provide a specific package of care will be critical to reducing HIV-associated morbidity and mortality and the burden of disease [6,13,15].…”

Incidence and determinants of mortality among HIV infected adult patients on antiretroviral therapy in Ethiopia: A systematic review and Meta-analysis

“…Early initiation of treatment before the development of advanced WHO clinical stage of the disease will reduce morbidity and prevent the high mortality rate occurred among patients with advanced WHO clinical stage of the disease (36,37,38).…”