Focusing on those with advanced HIV in the era of 'Treat All'
In the era of treat all, renewed emphasis is needed on the 39% of people living with HIV who start treatment late who are at an increased risk of deaths and opportunistic infections.
New World Health Organization (WHO) guidelines now recommend an enhanced package of interventions for people starting antiretroviral treatment (ART) late, to help drive down death rates and opportunistic infections among this group.
Currently, some 10% of people with advanced HIV disease – defined by the WHO as having a CD4 count of fewer than 200 cells/mm3, or having an HIV-related opportunistic infection – die within the first three months of starting treatment. This proportion is thought to be much higher in low-resourced settings.
People with low CD4 counts are at risk of developing and dying from tuberculosis (TB), cryptococcal meningitis and other severe bacterial infections, as their body is unable to sustain an adequate immune response.
Late treatment starters are also at risk of immune reconstitution inflammatory syndrome (IRIS) when they start treatment – whereby the immune response immediately after treatment initiation is so strong that it actually exacerbates existing infections or leads to new ones due to intense inflammation.
The new recommendation calls for the screening of TB in symptomatic patients, as well as screening for the cryptococcal antigen in people with CD4 counts bellow 100 cells/mm3. Depending on the results of these two tests, they will then start an intensified prophylaxis and pre-emptive treatment programme, rapid ART initiation (if not immediately, within seven days of diagnosis) and intensified adherence support.
While all these interventions are already individually recommended by the WHO, the new package of recommendations provides a standardised and simplified package of priority HIV interventions for clinicians.
The new guidelines were presented at the International AIDS Society (IAS) Conference on HIV Science in Paris this week, and were informed by results from an open-label trial published in the New England Journal of Medicine in advance of the conference.
The trial demonstrated the benefits of the enhanced antimicrobial prophylaxis package on care outcomes across sub-Saharan Africa. The relative death rate was 27% lower among patients who received the intervention after 24 weeks, with the benefits maintained to 48 weeks. These patients also had significantly lower rates of hospitalisation, IRIS-related events, tuberculosis, cryptococcal infections and other severe opportunistic infections.
In the era of getting everyone living with HIV on treatment straight away – for their own benefit but also for wider HIV prevention – the guidelines are a reminder of the fact that a significant proportion of people still do not present to care until very late, and their needs need to be urgently addressed.
Dr Carl Dieffenbach from the US National Institutes of Health, told the BBC that the package was similar to the early days of the epidemic when there was more emphasis on treating opportunistic infections.
"I think it's the best possible medicine you could be doing, the challenge for health departments around the world is they've largely felt they could get out of dealing with the opportunistic infections.
"They can't neglect this population of patients, it's not enough to just put them on antiretroviral therapy."