1. advanced HIV disease and associated mortality : how can we do better
advanced HIV disease and associated mortality : how can we do better ? Eric Goemaere, MD, PHD MSF Southern Africa School of public health and family medicine, UCT, Cape Town

2. AIDS related deaths , UNAIDS 2017 report
reduction

3. Evolution of CD4 < 100 cells/µL initiation , South Africa , National /Eshowe, KZN district
Sergio Camora NHLS, South Africa
Adult ART initiations : DHIS data
TIER. Net data : MSF Eshowe KZN

4. Proportion with CD4 < 100 at initiation Kinshasa and Conakry health centres (low prevalence, MSF supported sites)
When looking at proportion of CD4 < 100 at initiation , this is not significantly decreasing in Kinshasa and Conakry health centres supported by MSF despite an increasing median Cd4 at initiation . No information available here on naïve/non naïve patients . As a results , all will be considered as ART naïve and treated accordingly .

5. HIV very advanced disease in Western Cape facilities, SA M. Osler, A
HIV very advanced disease in Western Cape facilities, SA M.Osler, A.Boulle (preliminary analysis, unpublished. Not for distribution )
43%
57%
Breakdown of naïve/non naïve ) presenting in all Western Cape health facilities available for WC due to electronic unique ID number
Total number of very advanced HIV disease ( < 50 cd4is stable if not recently increasing
Breakdown shows that 57 % of them are non ART naïve , mix of re-presenters ( majority ) and treatment failures ( minority at such late stage )

6. ART treatment cascade: where do advanced disease come from ?
Re-admission after interruption
Front door
Side doors
PITC
Linkage to Care
Retention in care
Community testing
Undetectable
Viral load
Late presenters
Treatment
Failures
Front door

7. ART exposure of people living with HIV at admission to referral hospitals
DRC, Kenya and Malawi
71%
80 %
60%
37%

8. Morbidity in MSF supported HIV Referral hospitals: Homa Bay, Kinshasa and Conakry
Homa Bay Hospital , Kenya, 2015
Main morbidity : TB always # 1 followed by neurological and bacterial infections
Date collection need to be standardized !!
Kinshasa, CHK , RDC Jan-Jun n= 1275
Donka Central Hospital, Guinea Conakry, Nov ‘16-Apr 2017 n=151

9. What to do within a public health approach to reduce HIV mortality ?
Advanced HIV patient in community
Primary Health Facility
Hospital
Srceening package
Rapid assesment unit
Adapt treatment literacy (failures, interruptions..)

10. At PHC level : comprehensive screening package to identify advanced disease /refer if necessary
Semi –quant CD4 LFA
CRAG
TB –LAM (< 100 Cd4)
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.
CD4
LAM
X-pert
CrAg LFA
CPT-CTX-B6
Same day max 2 weeks ART ?
Follow up

11. Referral hospital level HIV/TB rapid assesment unit ( RAU)
Referral level : essential component of a Rapid Assesment Unit for HIV specific presentations

12. No time to waste !! 25 to 35 % death within next 48 hrs
Specific screening algorithm to be used in the RAU

13. Routine VL monitoring: progress in mesuring but not in action !
System related barriers
2nd line drug stock outs
decentralisation/task shifting
2nd line committees
Lack of focal staff – no follow up
Regulatory : 2nd line nurses
Patient fear…
2015: 35%
2016: 24%
2017: 13%

14. Accelerated viral load & 2nd switch ?
At PHC level
2nd line switch if per standard algorithm
Triggered VL /referral if unstable
At referral level
after 1 VL>1000
if CD4<100 - unstable stage IV - interrupter / failing for more than 6 M
If pregnant
Empirical
Clinically failing , stage IV,CD4 < 100
No VL result available within 3 DAYS
-> Switch back if VL suppressed subsequently ?
Classical WHO VL algorithm is based on naïve patient -> TAT is way to long -> very few patients switched to 2nd line
Need to be adapted for ART experienced patients

15. What to do within a public health approach to reduce HIV mortality ?
Well
Clinically unwell
Naïve asymptomatic
Baseline CD4 and stage
CD4 < 200/100 to trigger package for advanced disease
LATE PRESENTERS
Naïve symptomatic
Management of diagnosed OIs
Referral as necessary
Baseline CD4 and stage
CD4 < 200/100 to trigger package for advanced disease
Naïve
All WHO guidelines for advanced disease up to now written for treatment naïve patients
New growing categories : ART treatment experienced either well ( ambulatory) or clinically unwell
TREATMENT FAILURES/INTERRUPTERS
Asymptomatic interrupter
Triggered CD4 & VL
CD4 < 200/ 100 to trigger package for advanced disease
Symptomatic/clinically failing
Triggered CD4 and VL
CD4 < 200/ 100 to trigger package for advanced disease
VL > consider expedited switch if on ART for > 6 mths
ART exposed

16. Post-discharge follow-up ?
GF Jooste , Cape Town : 29.9% readmission / 13.3% died (90 days)
Homa bay, Kenya : post discharge mortality: 30 %charge follow-up : r
Kinshasa CHK : 30 % readmitted ..once ,10 % twice.
Where ?
back to PHC level /clear management plan & criteria for up-referral
Close follow-up : Wk 2, mth 1 , mthly for 6 mths
Link with community based expert client
By who ? ( integration in differentiated model of care framework )
Clinical office/ Nurses ad-hoc training
24hrs hotline

17. Some priority gaps MSF will contribute to research
Treatment
Impact of rapid VL switch on mortality
Empirical treatment for those with CD4 < 100, unstable
TB : if TB-LAM negative => clinical decision
Same days post TB ART re-initiation : steroids ?
Diagnostics (POC)
CD4 LFA
TB LAM on centrifuge urines & CrAG at 200 Cd4
Toxoplasma
ARV point mutation

18. Conclusions
Reducing HIV mortality is one of our key challenge with ARV resistance rising
It will require:
bold service/guidelines adaptations and staff training
a fine balance between hospital based strategies and community/primary health care ones to keep in line with a public health approach
additional resources

19. Acknowledgements www.samumsf.org
MSF clinical staff DRC, Malawi, Guinea, SA
Colleagues in SAMU & Epicentre
Colleagues at center for Infectious disease and epidemiological research (CIDER) ,UCT, Cape Town