A study presented at the 12th International AIDS Society Conference on HIV Science (IAS 2023) by Dr Shrikala Acharya of the Mumbai District AIDS Control Society shows that it is feasible to integrate an advanced HIV care package in 17 government-run ART centres in Mumbai, India, without any additional human resources. More importantly, it helps save lives.
It is not new knowledge that those with advanced HIV disease are at high risk of death, even after starting antiretroviral therapy (ART). This risk increases as the CD4 count drops. That is why World Health Organization (WHO) guidelines call for providing an advanced HIV care package for all those with advanced HIV disease, so as to prevent or manage life-threatening infections. All those with a CD4 count below 200, or symptomatic HIV disease (WHO stages 3 or 4), and all children with HIV below five years should be offered the advanced HIV care package.
The package includes interventions to screen, treat or prevent major opportunistic infections that may result in severe disease or death, including tuberculosis (TB), severe bacterial infections, and fungal cryptococcal infection (the cause of cryptococcal meningitis). Depending on eligibility, people should be offered prophylaxis with cotrimoxazole, flucanozole and TB preventive treatment. Everyone with advanced HIV should be offered rapid ART initiation (same day or within a week) and adherence support.
But how feasible is it for government HIV programmes in countries such as India to integrate and sustain provision of the advanced HIV care package in routine care?
“Mumbai experience provides much needed evidence that implementing advanced HIV care package is feasible in routine public healthcare setting with the existing patient flow without additional staff at ART centre,” study author Dr Shrikala Acharya told aidsmap. “We had developed standard operating procedures for advanced disease management among those people with advanced HIV disease, and trained the staff of ART centres in fast tracking and screening with tests such as LF-LAM and CrAg.”
The two tests are important as they help triage those with TB or cryptococcal infection for further management. The LF-LAM (Lateral Flow LipoArabinoMannan Assay) urine test is a WHO-recommended point-of-care test to screen people for TB which has better sensitivity for TB among people with HIV. The CrAg test is a screening test for cryptococcal infection. Dr Acharya added the availability of point-of-care tests was helpful, and that measures were put in place to ensure adequate stock of prophylactic medication and test kits in all 17 ART centres.
Out of 38,042 people with HIV enrolled for ART at 17 ART centres in Mumbai, India, 4334 people were identified with advanced HIV disease between November 2020 and December 2021. This was primarily through CD4 testing, rather than clinical staging. Out of those with advanced HIV, 64% were given the advanced HIV care package – and 88% of them survived.
Two-thirds were male, the median age was 43 and half had a CD4 count below 137, with a quarter having fewer than 80 CD4 cells.
Only one-fifth of people with advanced HIV disease were ART naïve. Around four-fifth of ART naïve people were initiated on ART within a week.
The large number of people with advanced HIV who had already received ART shows that those on ART should be monitored and given enough support to remain on ART and avert CD4 counts dipping so low. ‘Undetectable equals untransmittable’ (U = U) was not a reality in the lives of all those who were part of this Mumbai study.
Almost half of those given the advanced HIV care package had latent TB (rather than active TB disease) and thus were found eligible for TB preventive treatment. While 84% were put on it, the regimen used for TB preventive treatment was not the short-course regimen which is recommended for people with HIV.
India’s prime minister announced in March 2023 that short-course TB preventive therapy for people with HIV (3HP – weekly dose of rifapentine and isoniazid for three months duration) will be made available, but this is yet to become a reality, Dr Ishwar Gilada told aidsmap.
Over 90% of the people in the study were screened for TB using lateral flow TB-LAM – and 7% of these had active TB disease, out of which 92% were linked to TB care services.
Around 96% of those who were offered the advanced HIV care package were screened for cryptococcal infection – and 25 individuals (0.9%) were found serum positive, with one person positive on a confirmatory test done with cerebrospinal fluid.
All people in the study were offered cotrimoxazole prophylaxis, which protects against pneumonia, other serious opportunistic infections and malaria, and 97% received it.
Availability in the private sector?
Out of 1.5 million people on ART in India, about 100,000 are receiving it from the private sector.
Dr Ishwar Gilada of the Unison Medicare and Research Centre, India’s first privately run comprehensive HIV care centre, told aidsmap that India’s national AIDS control programme needs to learn from national TB elimination programme on leveraging public-private partnerships more effectively.
People with drug-resistant TB seeking care in private healthcare settings like his can receive bedaquiline based anti-TB therapy from government supplies. However, key elements of the advanced HIV care package are not available.
“Why are privately managed patients not able to access public-sector drugs and follow-up tests like CD4 and viral load?” he asked.
Acharya S et al. Feasibility of implementing advanced disease management package as part of routine, standard of HIV care at ART centres in Mumbai, India. 12th IAS Conference on HIV Science (IAS 2023), Brisbane, abstract EPE0862, 2023.