Advanced HIV: New SAMU guidelines for referral centres

By
Rosie Burton
Ian Proudfoot
for on 28/05/2018

In the last two years, the concept of ‘advanced HIV disease’ has evolved rapidly with a huge drive by assorted international bodies, including WHO, to define concepts and implement strategies that address patients presenting with CD4 counts below 200 or those presenting with new stage three or four diseases. It is being increasingly noted that many of these patients have already been on ART before and are often failing their existing treatment.

The four stages of managing advanced HIV

MSF’s clinical experience in managing advanced HIV shows that the challenge should be approached at four levels – in the community, in primary health clinics, in hospitals and again in primary care after discharge.

Each of these levels is important in its own right.

  • Community awareness should be increased on the danger signs of advanced HIV.
  • Clinicians in primary care need to be able to detect the many illnesses associated with advanced HIV before the patient becomes ill enough for admission to hospital.
  • In hospitals, clinicians need to be able to manage a specific set of illnesses associated with high mortality.
  • After discharge, good communication between hospitals and primary care clinics to which patients are returning is essential to maintain continuity of care and reduce subsequent readmission or death.

SAMU – with input from MSF’s Aids Working Group - is updating its range of clinical resources at these four levels to support today’s health staff. The clinical resources required at primary care level will form a small but important part of the new edition of the ‘HIV/TB Clinical Guide (last published 2015, 8th edition)’, on track to be launched in English in August 2018, and in French by October 2018.

Saving lives at hospital level

It’s 4am in the emergency room. An extremely ill AIDS patient arrives in respiratory distress or with signs of severe toxoplasmosis such as confusion or reduced levels of consciousness. Where does a busy clinician start?

The ‘MSF HIV/TB guideline – Hospital Level’ - updated in February 2018 - contains clear, practical guidelines to help the hospital clinician quickly identify and manage the common conditions with which sick HIV positive patients are referred to emergency units and wards in hospitals, especially those with minimal resources.

Hospital level guide

As severely ill AIDS patients run a very high risk of death, the most important factor is speed. It’s critical to make rapid decisions to diagnose and treat patients within hours of admission using the available resources in terms of point-of-care investigations and therapeutic drugs.

The updated referral guidelines – presented as step-by-step algorithms – therefore break down the main clinical presentations of AIDS patients into a few broad ones, to identify what investigations to do to detect the main causes, and importantly, those that can be excluded. Going down the wrong track when time is limited can be fatal.

Advanced HIV
An MSF nurse checks the neurological presentation of a patient recently admitted at MSF’s AIDS centre, Kinshasa, Democratic Republic of Congo

Based on real-life clinical experience in low resource settings

The SAMU referral guidelines are based on the combined clinical experience of MSF staff working in hospitals across sub-Saharan Africa. They provide guidance on on immediate, individualized patient care, assuming that clinicians don’t have access to specialists or referral beyond where they are, or specialized equipment and laboratories.

The review process is extensive, with technical input from clinicians across a wide range of MSF’s HIV/TB projects. As such, they offer the most practical route yet to treating advanced HIV in a low-resource setting. These guidelines are being extensively used in MSF’s HIV inpatient services in West, Central and Southern Africa.

That said, new evidence on treating advanced HIV is emerging, resulting  in differing opinions amongst clinicians on what constitutes  best practice. The guidelines thus remain a work in progress and will be updated as MSF’s experience evolves.

Addressing advanced HIV at all levels will need a broad approach that will need increased education in communities and improved clinical skills in primary care clinics and hospitals. At the same time, advocacy will be essential in pushing for wider access to essential drugs and critical point-of-care tests that can in turn improve clinical diagnosis and ultimately save lives.

Download ‘MSF HIV/TB guideline – Hospital Level’ here:  https://samumsf.org/en/resources/hiv/advanced-hiv-disease/msf-hivtb-guide-hospital-level