Opinion Paper - Special Collection: UNAIDS Targets for 2030

Establishing targets for advanced HIV disease: A call to action

David B. Meya, Lillian Tugume, Vennie Nabitaka, Proscovia Namuwenge, Sam Phiri, Rita Oladele, Bilkisu Jibrin, Mojisola Mobolaji-Bello, Cecilia Kanyama, Werner Maokola, Sayoki Mfinanga, Cordelia Katureebe, Ikechukwu Amamilo, Brian Ngwatu, Joseph N. Jarvis, Thomas S. Harrison, Amir Shroufi, Radha Rajasingham, David Boulware, Nelesh P. Govender, Angela Loyse
Southern African Journal of HIV Medicine | Vol 22, No 1 | a1266 | DOI: https://doi.org/10.4102/sajhivmed.v22i1.1266 | © 2021 David B. Meya, Lillian Tugume, Vennie Nabitaka, Proscovia Namuwenge, Sam Phiri, Rita Oladele, Bilkisu Jibrin, Mojisola Mobolaji-Bello, Cecilia Kanyama, Werner Maokola, Sayoki Mfinanga, Cordelia Katureebe, Ikechukwu Amamilo, Brian Ngwatu, Joseph N. Jarvis, | This work is licensed under CC Attribution 4.0
Submitted: 14 May 2021 | Published: 10 August 2021

About the author(s)

David B. Meya, Department of Research, Infectious Diseases Institute, Makerere University, Kampala, Uganda; and, Department of Medicine and International Health, University of Minnesota, Minneapolis, United States of America
Lillian Tugume, Department of Research, Infectious Diseases Institute, Makerere University, Kampala, Uganda
Vennie Nabitaka, HIV Department, Clinton Health Access Initiative, Kampala, Uganda
Proscovia Namuwenge, Department of HIV Care and Treatment, Ministry of Health, Uganda, Kampala, Uganda
Sam Phiri, HIV Department, Lighthouse Trust Malawi, Lilongwe, Malawi
Rita Oladele, College of Medicine University of Lagos, Lagos, Nigeria
Bilkisu Jibrin, Department of HIV Care, Treatment and Support, Ministry of Health, Lagos, Nigeria
Mojisola Mobolaji-Bello, Department of HIV Care, Treatment and Support, Ministry of Health, Lagos, Nigeria
Cecilia Kanyama, Department of Medicine, University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
Werner Maokola, National AIDS Control Program, Ministry of Health, Tanzania, Dar-es-Saalam, Tanzania
Sayoki Mfinanga, Department of Research, Muhimbili Medical Research Centre, Dar-es-Salaam, Tanzania
Cordelia Katureebe, Department of National HIV Care and Treatment, Ministry of Health, Kampala, Uganda
Ikechukwu Amamilo, Global Health Access Program, Clinton Health Access Initiative, Abuja, Nigeria
Brian Ngwatu, HIV Program, Clinton Health Access Initiative, Kampala, Uganda
Joseph N. Jarvis, Department of HIV, London School of Hygiene and Tropical Medicine, London, United Kingdom
Thomas S. Harrison, Centre for Global Health, Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom
Amir Shroufi, Department of HIV, Centres for Disease Control Foundation, Atlanta, United States of America
Radha Rajasingham, Department of Medicine and International Health, University of Minnesota, Minneapolis, United States of America
David Boulware, Department of Medicine and International Health, University of Minnesota, Minneapolis, United States of America
Nelesh P. Govender, Department of Research, National Institute for Communicable Diseases, Johannesburg, South Africa
Angela Loyse, Department of Research, Centre for Global Health, Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom


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Abstract

The World Health Organization (WHO) has published a guideline for the management of individuals with advanced HIV disease (AHD) to reduce HIV-related deaths. The guideline consists of a package of recommendations including interventions to prevent, diagnose and treat common opportunistic infections, including tuberculosis (TB), cryptococcosis and severe bacterial infections, along with rapid initiation of antiretroviral treatment and enhanced adherence support. Currently no clear targets exist for these key interventions. Emerging programmatic data from Uganda, Tanzania and Nigeria suggest that an estimated 80% of eligible people continue to miss the recommended cryptococcal or TB testing, highlighting the remaining challenges to the effective implementation of WHO-recommended AHD packages of care in real-world resource-limited settings. The absence of mortality indicators for the leading causes of HIV-related deaths, because of the lack of mechanisms to ascertain cause of death, has had a negative impact on establishing interventions to reduce mortality. We suggest that setting 95-95-95 targets for CD4 testing, cryptococcal antigen and TB testing, and treatment that are aligned to the WHO AHD package of care would be a step in the right direction to achieving the greater goal of the WHO End TB strategy and the proposed new strategy to end cryptococcal meningitis deaths. However, these targets will only be achieved if there is healthcare worker training, expanded access to bedside point-of-care diagnostics for hospitalised patients and those in outpatient care who meet the criteria for AHD, and health systems strengthening to minimise delays in initiating the WHO-recommended therapies for TB and cryptococcal disease.

Keywords

advanced HIV disease; cryptococcal antigen; tuberculosis; TB-LAM; targets

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