With the huge increase in ART access and the transformation of HIV treatment into a chronic treatable disease, many thought that AIDS would disappear. Yet global deaths from HIV have plateaued in the last two years, at around 1 million deaths a year. Nearly one third of HIV patients are still being diagnosed with HIV at a late stage of the disease.
Overwhelming evidence from across Africa now shows that AIDS-related death and disease has not gone away, and is moreover increasingly seen in people who have received ART treatment before. Rather than following a neat linear cascade towards lifelong health, as implied by the globally-agreed 90-90-90 targets, many patients have complicated individual journeys, repeatedly cycling in and out of treatment. Leading causes of death among adults with AIDS-related disease globally include preventable diseases including Tuberculosis, severe bacterial infections, cryptococcal meningitis, toxoplasmosis and pneumocystis pneumonia.
The HIV-ADC launches
The growing recognition of this unacceptable trend has brought together a collective of concerned bodies under The Global HIV Advanced Disease Consortium (HIV-ADC). The consortium currently includes 15 international health organisations including MSF, CDC, WHO, ICAP/CQUIN, EGPAF, CHAI, ASLM and is open to all health ministries. At its first official meeting in Kampala, Uganda on 12 April 2018, the HIV-ADC agreed on a common vision: to rapidly begin reducing global AIDS-related deaths by improving access to diagnostics and treatment for opportunistic infections. Among other objectives, the group will advocate for the widespread implementation of the new WHO-recommended package of care for managing people with advanced HIV disease.
HIV-ADC offers a strong community of practice for exchange and collaboration on similar situations seen in different parts of the world. Participants at the Kampala meeting included world-renowned specialists in opportunistic infections such as toxoplasmosis, cryptococcal meningitis, rare forms of TB and even histoplasmosis and talaromycosis, looking to lend their expertise in adapting the diagnostics and treatment of wealthy countries to field realities in poorer settings.
Encouragingly, a shared willingness from all sides is being seen to share new clinical strategies and experiences to reduce AIDS-related deaths. This is not disconnected from broader prevention efforts, but rather aims to address the specific needs of individual patients. Without negating the public health perspective, this approach intends to re-balance epidemic control with a clinical humanitarian approach by reducing deaths.
MSF has a key role to play in the HIV-ADC by bringing our frontline experience from across multiple countries, projects and operational centres. We already have strong collaborative efforts underway in many settings to test the feasibility of and provide data on the yield and impact of diagnostic and therapeutic packages of care on AIDS-related mortality.
MSF’s response to advanced HIV
At the same time, MSF’s practical response to advanced HIV is evolving. Initially, we up-skilled and strengthened hospitals to manage the continual influx of AIDS patients being seen. Yet we soon recognised that access to CD4 monitoring was poor and needed to increase. Without detecting low CD4 counts much, much earlier – at clinics and in communities – for many our care was simply too late. Once CD4 counts reach below 50, chances of survival are greatly reduced.
At primary health level, SAMU is developing guidelines to help clinicians quickly identify and triage patients in the waiting area, and offer those with danger signs a comprehensive screening package (consisting of simple point-of-care CD4, CrAg, urine TB LAM and GeneXpert diagnostic tests) to identify advanced diseases related to HIV. These tests are ideally done in under an hour, enabling quick decisions to be taken, including referral.
The viral load algorithm – originally designed for stable HIV patients – is being adapted according to danger signs, CD4 count and treatment experience, thereby accelerating the clinician’s ability to change a patient’s treatment if necessary. We can’t afford to let patients wait 6 to 12 months on failing ART treatment before switching them to more effective regimens. They may never come back!
At community level, we want to reframe patient education and are adapting existing information materials to better reflect the non-linear nature of treatment adherence. We want to open dialogue with patients who decide to stop treatment, allowing them decision-making power to enable their return.
From MSF’s experience of treating AIDS in hospitals, a large proportion of patients die within 48 hours of admission. Referrals can exhaust valuable time that could be used to save the patient’s life, and many hospitals are not usually equipped to immediately deal with advanced HIV admissions. We are therefore piloting Rapid Assessment Units in Nsanje (Malawi), Maputo and Beira (Mozambique) which are placed within hospital emergency units and equipped, including with a 24-hour mini-laboratory, to quickly identify and start to address stage 4 diseases.
HIV-ADC – a valuable platform for MSF
As we evaluate each intervention, the HIV-ADC will provide a platform for MSF to share our findings, solutions and needs to a wide cross-section of actors - including technical implementers, researchers, funding agencies, and pharmaceutical and diagnostics manufacturers - for greater political and practical impact.
One area of potential work for MSF could be identifying and evaluating the feasibility of point-of-care diagnostic tools to screen for opportunistic infections such as pneumocystis pneumonia, toxoplasmosis and severe bacterial infections which could be used at decentralized sites. These infections represent a considerable burden among people with advanced HIV but remain under-diagnosed. A key example of concrete application is a new point-of-care CD4 lateral flow assay from Omega Diagnostics. Prototypes exist but are not yet at the sensitivities required.
MSF’s advocacy agenda – which tackles the many blockages to an improved AIDS response – was unanimously adopted by the consortium, which challenges us to continue building evidence to speed up the national adoption of packages of care for advanced HIV in the countries where we work. Opportunities exist to influence funding agencies such as PEPFAR, Global Fund and UNITAID to invest more in addressing market shortcomings to increase availability and affordability of existing and upcoming products to tackle advanced HIV disease.
For instance, UNITAID intends to invest in key commodities such as point-of-care CD4, CrAg, TB LAM diagnostic tests, and amphotericin B, flucytosine and fixed-dose-combination cotrimoxazole/B6/INH to spur demand and bring prices down. They will however need to collaborate with implementing partners like MSF to address supply and delivery aspects.
We cannot accept that advanced HIV is inevitably fatal. With better diagnostics and treatment delivered earlier, the majority can be saved. We must continue to bring our voice and efforts to forums like the HIV-ADC to collectively address this unfinished agenda.
About The Global HIV-ADC:
The Global HIV Advanced Disease Consortium is dedicated to reducing global mortality from HIV/AIDS including by facilitating rapid implementation of the WHO-recommended package of care for people living with advanced HIV diseases.
Selected presentations from the HIV-ADC meeting in Kampala (12 April 2018), including MSF presentations, are available for download (under Additional Media on right hand side).
Current members of HIV-ADC:
African Society of Lab Medicine (ASLM), Centers for Disease Control and Prevention (CDC), Clinton Health Access Initiative (CHAI), Global Action Fund for Fungal Infections (GAFFI), Global Health Impact Group (GHIG), International AIDS Society (IAS), ICAP at Columbia University, International Diagnostics Center (IDC-dx), IRESSEF (Senegal), IS Global, Medecins sans Fronteires (MSF), St. Georges University of London (SGUL), UNITAID and World Health Organization (WHO), various Health Ministries and HIV/AIDS programmes.