Global attention needed to prevent and treat AIDS in antiretroviral era
An unacceptably high number of people from sub-Saharan Africa have been left out of the global HIV response—without access to treatment or medical care—and they continue to develop and die from AIDS-related diseases, according to data released by the international medical humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) at the International AIDS Society (IAS) Conference on HIV Science in Paris Tuesday.
According to MSF’s briefing paper, “Waiting isn’t Option: Preventing and Surviving Advanced HIV,” and data presented at IAS, patients at MSF-supported hospitals in the Democratic Republic of Congo (DRC), Guinea, Kenya, and Malawi arrive in a state of such severe immune failure that overall mortality for patients presenting with AIDS is between 30-40 percent. Almost one-third of people with AIDS die within 48 hours of reaching the hospital.
The main causes of illness and death are due to treatment failure or interruption or late diagnosis leading to delayed treatment. Unlike in the early 2000s, when little treatment was available, more than 50 percent of people with AIDS at referral hospitals supported by MSF had already started antiretroviral therapy (ART), with many showing clinical signs of treatment failure.
“Despite extensive access to antiretrovirals, there has not been the expected drop in late-stage presentations of HIV in developing countries,” said David Maman, MSF Epicentre epidemiologist. “What’s different is that among people admitted to hospitals, the majority are already diagnosed and many have been on treatment for several years. In Kenya, in Homa-Bay, where antiretrovirals have been available for years, half of the AIDS cases in the hospital show signs of treatment failure. We’re pushing to switch these patients to second-line antiretroviral treatments more rapidly.”
At the community level, MSF population surveys also show that a proportion of people living with AIDS in communities in southern and eastern Africa remain untested and untreated. Around 10 percent of people living with HIV in districts of Malawi, Kenya, and South Africa had AIDS, of which 47 percent had never received testing or treatment.
“People are still being diagnosed late,” said Gilles van Cutsem, MSF HIV Advisor. “We need new ways to detect those left out, early on, before they arrive at hospital in often fatal condition or die at home without ever receiving care. Stigma and lack of information still remains high, leading to delayed treatment or no testing and treatment at all. This illustrates the need to complement increased antiretroviral coverage at community level with improved care for those who have been on treatment for years.”
Clinicians, including from MSF, have increasingly voiced concern over the lack of attention and means going towards the prevention and treatment of AIDS across Africa. The World Health Organization (WHO) recently issued its first ever set of guidelines for the treatment of AIDS in low-resource settings. While this is a positive step forward, MSF calls for the urgent implementation of the guidelines and measures that would address potential drug resistance and treatment failure.
Key interventions urgently needed to prevent and treat AIDS include the rapid rollout of “test and start,” which allows someone to be tested and put on treatment immediately rather than waiting until the next appointment; CD4 baseline testing at ART initiation, which measures how well one’s immune system is working when ART is started to give doctors something to compare future CD4 counts with; routine viral load testing to keep track of how much of the HIV virus is in one’s blood; point of care diagnostics for tuberculosis, which tests for TB and gives same-day results; improved treatment for cryptococcal meningitis; rapid switch to second-line ART for failing and advanced patients; and swift, effective, and accessible treatment for opportunistic infections. MSF is also calling for models of care geared towards prevention, treatment, and support for patients with AIDS, and free specialized hospital-based care free of charge for patients.
The situation will be exacerbated as funding for the global HIV response continues to stagnate, said MSF. Anticipated cuts in US funding to the Global Fund (17 percent) and PEPFAR (11 percent) from 2018 onwards will see many countries facing further grant restrictions. Shrinking funding and the need to preserve the purchasing of antiretroviral treatments will imperil community responses, including targeted testing and improved treatment literacy and adherence, while starving essential investments needed for health workers, laboratory, and diagnostics.
“Each patient presenting with AIDS is a terrible testimony to the challenges to get timely access to test and treatment and to continue their ART uninterrupted,” said Mit Philips, MSF Health Policy Advisor. With global political will and funding for HIV on the decline, not only is the broader fight against the virus at risk go into reverse, but specifically these patients arriving at hospitals sick with AIDS will have any hope of reprieve snatched away.”
MSF currently supports more than 230,000 people living with HIV on antiretroviral treatment in 19 countries, with a focus on free quality care, including test & treat approaches, improved adherence support ,and differentiated models of care.
MSF directly provides or supports the provision of free hospital-based care for the treatment of AIDS in four hospitals in sub-Saharan Africa. In Homa Bay district hospital (200 beds) and referral health centres in Kenya, MSF supports and trains medical staff and provides medical equipment, laboratory support ,and drugs to improve the treatment of opportunistic infections (OI). In the Nsanje district hospital (200 beds), in Malawi, MSF is training medical staff to improve diagnosis and clinical management of HIV/AIDS patients, while increasing laboratory services, pharmacy support and supplies for the treatment of opportunistic infections. MSF runs a specialised AIDS care unit in Donka Hospital (31 beds) in Conakry and in Kabinda Hospital (42 beds), in Kinshasa, DRC, and supports Roi Baudoin Hospital, also in Kinshasa. These centres work with peripheral health centres to improve patient referrals and provide hands-on training to improve the overall quality of care for HIV/AIDS patients. In all HIV projects, MSF teams are developing and implementing packages of diagnostics and treatment for HIV/AIDS, along with improved treatment literacy and adherence support.