How to ensure access to diagnostics and CD4 testing
According to WHO, CD4 cell count testing is essential in identifying people with AHD who should access the recommended package of care. The test measures the number of CD4 cells in the blood — the white blood cells responsible for finding and destroying bacteria and viruses in the body. It shows the strength of the immune system and can predict how likely someone is to contract an opportunistic infection such as cryptococcal meningitis or tuberculosis.
What are Opportunistic infections?
Opportunistic infections are infections that occur more often or are more severe in people with weakened immune systems than in people with healthy immune systems. People with weakened immune systems include people living with HIV. OIs are caused by a variety of germs — viruses, bacteria, fungi, and parasites.
Source: National Institutes of Health
“For a lot of countries the biggest barrier is access to CD4 [testing]. We saw that with the “Treat All” [strategy] and the introduction of viral load monitoring the perceived importance of CD4 in some places fell off a cliff and CD4 use in some countries nosedived,” said Shroufi. There's a lot of ground to make back in some countries that were previously widely using CD4 testing, but later almost stopped using it, he explained.
“In Mozambique, CD4 testing is mainly financed by external parties and there has been almost total rupture. This is important to say because CD4 is the door, the entrance for advanced HIV disease,” said MSF’s Gutierrez Zamudio. “If there is no CD4 at primary level and hospital level, advanced HIV disease is not found.”
According to Shroufi, even once you've ascertained that someone has AHD, there are further barriers such as staff training and capacity, as well as the availability of therapeutics and diagnostics. Introducing new diagnostics and therapeutics has to be accompanied by training of health practitioners, he said.
“Hospitals use what they’ve used before and order what they’ve ordered before,” Shroufi said.
“Forecasting is based on historical data, so to get something new into the systems requires a proactive effort on someone’s part, ideally the ministry of health’s.”
Dr. Amir Shroufi
Medical Advisor in South Africa
CDC Foundation
According to a recent Devex survey of over 700 global health professionals from 90 countries, the most important factor in addressing AHD is:
59%
52%
45%
Building the capacity of health care personnel in identifying and handling AHD cases
Intensified support interventions for patient adherence to antiretroviral therapy
Expanding access to diagnostic tools and services / Government policy for AHD
Botswana is a small country with a population of only 2.4 million people where CD4 testing plays a big role in HIV care.
“For those with advanced HIV, we test at baseline, three months, six months, twelve months, and then annually. For those with a high CD4 count [over 200], it’s at baseline, three months, and then annually. That's how we do it here,” said Charles Muthoga, a health economist and research associate at Botswana Harvard AIDS Partnership.
Photo: MSF/Amanda Bergman
Photo: MSF/Amanda Bergman
Photo: MSF/Amanda Bergman
“CD4 remains a very important predictor in morbidity and mortality for HIV patients.”
Charles Muthoga
Health Economist and Research Associate
Botswana Harvard AIDS Partnership