Advanced HIV: a WHO perspective Nathan Ford & Meg Doherty Dept HIV & Global Hepatitis Programme World Health Organization

Late presentation: a persistent challenge World Health Organization 28 November 2018 Late presentation: a persistent challenge CD4 at start of ART Advanced disease at enrolment (CD4 <350) 306 CD4 among people starting ART is rising, but still remains low overall, with many people still starting ART at CD4 less than 200. There are also many losses between diagnosis and start of ART. 167 IeDEA-WHO Collaboration 2015

WHO Recommendations on Differentiated Care Data from recent trials shows that ART can be successfully initiated rapidly after HIV diagnosis – even on the same day. WHO recommends that efforts should be made to accelerrate start of ART. Patient readiness remains critically important Duncombe C, et al. TMIH 2015; Waldrop G, et al. TMIH 2016

World Health Organization 28 November 2018 WHO recommendations Cotrimoxazole prophylaxis CD4 ≤350 ALL where SBI/malaria highly prevalent Isoniazid prophylaxis ALL (after active TB ruled out) Cryptococcus antigen testing & pre-emptive therapy CD4 <100 Urine Lam for TB diagnosis Rapid ART Co-formulated tablet in development CD4 among people starting ART is rising, but still remains low overall, with many people still starting ART at CD4 less than 200. There are also many losses between diagnosis and start of ART.

Raising CD4 at start of ART World Health Organization 28 November 2018 Raising CD4 at start of ART Countries are rapidly adopting “Treat All” Marked improvements in CD4 following guideline changes As this slide shows, many countries have already adopted “Treat All” and others are planning to do so in the coming months

Rapid ART start Evidence New studies show that ART can be started on same day as HIV diagnosis Data from recent trials shows that ART can be successfully initiated rapidly after HIV diagnosis – even on the same day. WHO recommends that efforts should be made to accelerrate start of ART. Patient readiness remains critically important WHO position Efforts should be made to reduce the time between HIV diagnosis and ART initiation based on an assessment of a person’s readiness

Areas for future Investigation Roles of vaccines and vaccine preventable disease associated with early mortality (ie pneumonoccus infection) Appropriate and rapid antibiotic treatment for those with fever and evidence of bacteremia