Establishing targets for advanced HIV disease: A call to action

Abstract

The World Health Organization (WHO) has published a guideline for the management of individuals with advanced HIV disease (AHD) to reduce HIV-related deaths. The guideline consists of a package of recommendations including interventions to prevent, diagnose and treat common opportunistic infections, including tuberculosis (TB), cryptococcosis and severe bacterial infections, along with rapid initiation of antiretroviral treatment and enhanced adherence support. Currently no clear targets exist for these key interventions. Emerging programmatic data from Uganda, Tanzania and Nigeria suggest that an estimated 80% of eligible people continue to miss the recommended cryptococcal or TB testing, highlighting the remaining challenges to the effective implementation of WHO-recommended AHD packages of care in real-world resource-limited settings. The absence of mortality indicators for the leading causes of HIV-related deaths, because of the lack of mechanisms to ascertain cause of death, has had a negative impact on establishing interventions to reduce mortality. We suggest that setting 95-95-95 targets for CD4 testing, cryptococcal antigen and TB testing, and treatment that are aligned to the WHO AHD package of care would be a step in the right direction to achieving the greater goal of the WHO End TB strategy and the proposed new strategy to end cryptococcal meningitis deaths. However, these targets will only be achieved if there is healthcare worker training, expanded access to bedside point-of-care diagnostics for hospitalised patients and those in outpatient care who meet the criteria for AHD, and health systems strengthening to minimise delays in initiating the WHO-recommended therapies for TB and cryptococcal disease.

Cryptococcal Antigen Screening and Missed Opportunities for Earlier Diagnosis Among People With HIV and Poor Virologic Control in the Bronx, NY

“…Studies to establish an association between the interval or frequency of screening and prevention of cryptococcosis may be difficult to conduct due to the low case incidence. Nonetheless, our data and other reports of missed opportunities for CrAg screening in the United States 28 and Africa 29,30 suggest a potential benefit from integrating CrAg screening into the routine care of ARTexperienced individuals in conjunction with efforts to enhance ART adherence. Unlike countries with higher prevalence of cryptococcosis and processes to promote screening for cryptococcal disease, 31 the United States relies on provider awareness and discretion to screen individuals atrisk.…”

“…1A). The overall cohort had a median age of 45.7 years [interquartile range (IQR), 33.0-55.0], 64.7% men, 52.5% Black, 38.0% Hispanic, 35.5% men who have sex with men, with a median absolute CD4 count of 24 cells/mm 3 (IQR, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33], and an HIV VL of 1816 copies/mL (IQR, 1056-2601).…”

Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the “treat all” era: a retrospective cohort study from rural Rwanda

“…Comparable risks of death among patients with advanced HIV were observed prior to the initiation of treat all in Uganda, Zimbabwe, Malawi, and Kenya [ 28 ]. Collectively, these studies and many others indicate patients with advanced HIV disease remain a vulnerable population in the treat all era [ 29 , 30 ]. In our study, the prevalence of advanced HIV was relatively low, 11 out of 27 deaths (41%) occurred among those with advanced HIV.…”

Improved Algorithm-Based Magnetic Resonance Images Combined with Computed Tomography in the Diagnosis of Acquired Immune Deficiency Syndrome Combined with Spinal Tuberculosis

“…Acquired immune deficiency syndrome (AIDS) is caused by human immunodeficiency virus infection and belongs to the immune system deficiency syndrome dominated by T-cell immunodeficiency [1,2].…”