Why is AHD still an issue despite ART scale-up?
While the availability and use of ART has skyrocketed in the past decades — of the 38 million people living with HIV, 25.4 million people are now on treatment — around 1 in 3 people living with HIV still present to care with AHD. According to a 2019 study of 15 African countries conducted by Médecins Sans Frontières, an increasing number of countries are addressing AHD in their national guidelines, yet progress has been slow, and funding — as well as implementation of the package of care for AHD — remains extremely limited.
Globally, AIDS related illnesses are reported as the leading cause of death among women aged 15-49 years.
Source: MSF
According to Dr. Amir Shroufi, medical adviser for the CDC Foundation in South Africa, it’s important to divide individuals with AHD into three groups:
1. Individuals who have never been on ART before.
2. Individuals who are on ART but are failing treatment.
3. Individuals who have been on ART but have been out of care and came back into care.
For many years, people had a very linear view of treatment where we imagined individuals would get on treatment, adhere to it, and remain on it, he explained.
“It didn't really account for the human complexity — people's lives are certainly not linear ... and the reality is that for a lot of people, having HIV is very far from their biggest concern,” Shroufi said.
“Even when we have complete ART scale up people are still going to get sick, people are still gonna drop out of care; we're still going to have advanced disease.”
Dr. Amir Shroufi
Medical Advisor in South Africa
CDC Foundation
Number of deaths from HIV-related illnesses
Source: WHO
2000
2019
According to a South African study from 2018, most HIV-related deaths result from treatment-experienced patients not being in continuous care. Therefore, innovative interventions to retain ART patients in effective care should be an essential priority within the HIV response.
If individuals can’t afford transport to a facility or face other social circumstances, which make it difficult for them to attend a clinic, additional support is needed to ensure they don’t fall out of care, explained Dr. Gozie Ujam, deputy director at Nigeria’s National Agency for the Control of AIDS. In Nigeria, adherence counselors go through lists of people who were supposed to attend a clinic to identify anyone who’s missed two or more appointments, he added. They are then sent out to the community to ascertain what’s happening with that particular individual and why they’re not showing up for care and treatment.
Stigma or self-stigma is another reason individuals might abstain from seeking care or from adhering to treatment, Ujam said.
“In this country, back in 2014, we enacted the HIV/AIDS Anti-Discrimination Act but we still need the buy in of the population … it needs to seep down to the community level.”
Dr. Gozie Ujam
Deputy Director
Nigeria's National Agency for the Control of AIDS
Dr. Ana Gabriela Gutierrez Zamudio, medical coordinator for MSF in Mozambique, has seen the need for targeting individuals with AHD first hand. For the past 15 years and until January 2021, MSF operated the Alto Maé referral center in the country’s capital Maputo.
“We found out very quickly that the continuity of care for patients with advanced HIV disease was also missing.”
Dr. Ana Gabriela Gutierrez Zamudio
Medical Coordinator
MSF in Mozambique
According to Gutierrez Zamudio, almost 60% of the patients who were referred to the clinic had a CD4 count of less than 200, meaning they had AHD. “We were providing ambulatory treatment, but some patients eventually needed to be hospitalized and there was a lack of a good linkage to care and continuity of care in hospital after discharge.”
Photo: MSF
Photo: Sandra Smiley/MSF
Photo: MSF