July 25, 2017
Written by Médecins Sans Frontières (MSF)
Global attention is needed to prevent and treat AIDS in antiretroviral era, with 50 per cent of hospital admissions in MSF hospitals already on treatment and showing signs of clinical failure.
Paris – An unacceptably high number of people continue to develop and die of AIDS-related diseases across sub-Saharan Africa. They remain left out of the global HIV response without access to treatment that prevents AIDS or the medical care they need, says Médecins Sans Frontières (MSF).
In MSF’s briefing paper Waiting isn’t Option: Preventing and Surviving Advanced HIV , data presented at the International AIDS Society (IAS) Conference on HIV Science in Paris highlights that in MSF-run and MSF-supported hospitals in Democratic Republic of Congo (DRC), Guinea, Kenya, and Malawi, people arrive with such severe immune failure that overall mortality for patients presenting with AIDS is between 30-40 per cent. Almost one third of those deaths occur within 48 hours.
The main causes of illness and death are due to treatment failure or interruption, and late diagnosis leading to delayed treatment. Unlike in the early 2000s, when little treatment was available, more than 50 per cent of AIDS admissions 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. What’s different is that among people admitted to hospitals, the majority are already diagnosed and many have been on treatment for several years”, says David Maman, MSF Epicentre epidemiologist. “In Kenya, in Homa-Bay, where antiretrovirals have been available for years, half of the patients hospitalised with AIDS cases show signs of treatment failure. We’re pushing to switch these patients to second-line antiretrovirals more rapidly.”
At 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 per cent of people living with HIV in districts of Malawi, Kenya, and South Africa had AIDS, of which 47 per cent had never received testing or treatment.
“People are still being diagnosed late. We need new ways to detect those left out, early on, before they arrive at hospital in an often fatal condition, or die at home without ever receiving care”, says Gilles van Cutsem, MSF HIV Advisor. “Stigma and a lack of information still remain 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 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) issued its first-ever guidelines for the treatment of AIDS in low-resource settings in July. While this is a positive step forward, MSF calls for the urgent implementation of the guidelines with additional measures to address potential drug resistance and treatment failure.
Key interventions urgently needed to prevent and treat AIDS include the rapid rollout of ‘test and start’*, CD4 baseline testing at treatment initiation, routine viral load testing, point of care diagnostics for tuberculosis, improved treatment for cryptococcal meningitis, the rapid switch to second-line antiretroviral treatment 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 specialised hospital-based care free of charge for patients.
In a new report, MSF is also concerned that the situation will only be exacerbated as funding for the global HIV response continues to stagnate. Anticipated cuts in US funding to the Global Fund to Fight AIDS, Tuberculosis and Malaria (17%) and PEPFAR (11%) from 2018 onwards will see many countries facing further grant restrictions. Shrinking funding envelopes and the need to preserve antiretroviral treatment purchases will imperil community responses, including targeted testing, and improved treatment literacy and adherence, while starving essential investments needed for health workers, laboratories and diagnostics.
“Each patient presenting with AIDS is a terrible testimony to the challenges of getting timely access to testing and treatment, and to continuing treatment uninterrupted”, says 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 of going into reverse, but these patients arriving at hospitals sick with AIDS will have any hope of reprieve snatched away.”
*Test and start – where people start antiretroviral treatment immediately upon a HIV-positive diagnosis
MSF currently supports over 230,000 people living with HIV on antiretroviral treatment in 19 countries, with a focus on free quality care, including test and 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), Malawi, MSF is training medical staff to improve diagnosis and clinical management of HIV/AIDS patients, while increasing laboratory services, pharmacy support and supplies of OI treatment. MSF runs a specialised AIDS care unit in Donka Hospital (31 beds) in Conakry and in Kabinda Hospital (42 beds), 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.