The 2021-2026 UNAIDS strategy aims to reduce the number of people dying from HIV/AIDS to 250,000 by 2025, while also rightly placing emphasis on prevention, rights, social and political determinants of health. Still, nearly 700,000 HIV-related deaths occurred in 2019, despite being in an era of “test and start” with free anti-retroviral treatment.
While there has been a 39% reduction of AIDS-related deaths since 2010, progress has stalled in recent years, highlighting that scale up of testing and anti-retroviral treatment alone is not sufficient to end HIV related deaths. To address this mortality, we need to focus on finding the most at-risk people living with HIV, make sure they have effective access to anti-retroviral treatment, and treat their opportunistic infections. Besides tuberculosis, severe fungal and bacterial infections (such as cryptococcal meningitis) remain the primary comorbidities and are also the primary causes of hospitalization and death among people living with HIV.
A decade ago, AHD was seen mostly among patients who were unaware of their HIV status, often because of a lack of HIV testing and anti-retroviral treatment availability. Today, however, in some MSF inpatient facilities, 75% of hospital admissions for advanced HIV are patients who are receiving anti-retroviral drugs, often for many years. This suggests that they may have interrupted their treatment and/or developed a resistant form of the virus. Unfortunately, this is not detected and treated early enough for most.
MSF has learnt that the HIV care cascade is not a linear process from testing, early initiation, consistent drug adherence and viral suppression, but a circular one, with many people needing help to re-engage into care after treatment interruption and/or failure. Studies have shown that nearly 25% of patients will interrupt their treatment at some point and that up to one third of patients starting or restarting anti-retroviral treatment have AHD. What follows is immune suppression, opportunistic diseases, hospitalization and death. In MSF-supported hospitals in Guinea, DRC, Kenya and Malawi, we witness a 30-40% mortality rate among patients with AHD.
Since the COVID-19 crisis has caused a drop in initiations of anti-retroviral treatment and in retention in care, the situation is expected to worsen and the number of people living with HIV facing tuberculosis, severe bacterial and fungal infections to rise. The deterioration of patients’ condition brings back the typical complications, putting their life at immediate risk. As anti-retroviral treatment no longer suppresses the virus, it goes rampant through their body, allowing opportunistic infections to flare up and once more transmit HIV to their partner or their baby.
Certain countries in the West & Central Africa region are especially hard hit in terms of mortality. One fifth of all AIDS-related deaths and for children four out of every ten deaths in the
world occur in this region. We should reach out to people living with HIV at risk with immediate and intensified action for early detection and treatment.
The UN High Level Meeting is a unique opportunity to ensure country commitments on these needs thus it should reflect and be built on this. Addressing AHD is key, and it is possible, but there are still important hurdles. Screening for AHD is possible using simple point of care1 technologies. This accelerates detection and treatment of the killing infections linked to AIDS and can therefore help to save lives. In Malawi for instance, combining point of care screening by lay cadres in health centres and a rapid assessment unit in hospital, allowed significant gain of time in diagnosis and starting treatment, leading to reduced mortality among hospitalised patients. Many National Guidelines do not yet include targeted AHD services. Availability and affordability of the medicines required to implement them is a key challenge in many countries, particularly in sub-Saharan Africa. Unfavourable markets with high pricing for certain commodities contributed to countries’ slow progress in adoption of AHD package of care.
There is an urgent need for a global commitment to accelerate the implementation of a package of care to prevent, detect and treat advanced disease, which includes early voluntary and confidential -testing, early treatment initiation, increased enabling measures for continuity and retention, and services that reach out and welcome people back in care, which will consequently prevent treatment failure and mortality, and improve early detection of advanced HIV disease.
Only by recognising the importance of AHD, the expected UN High Level Meeting declaration will allow to curb HIV related mortality, contributing to removing these obstacles and throwing a lifeline to people with advanced HIV disease.
Dr Gilles van Cutsem is the leader of the MSF HIV/AIDS working group.
Amanda Banda is an MSF HIV advocacy consultant.