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STUDY: Adopting WHO guidelines to reduce advanced HIV disease and related deaths

Jan. 4, 2023
STUDY: Adopting WHO guidelines to reduce advanced HIV disease and related deaths
A snip from the Open Forum Infectious Diseases journal with insets of four Ifakara Health Institute researchers who contributed to the study and publication. GRAPHIC | IFAKARA/KMC.

Scientists are calling for urgent actions to be taken in order to reduce the burden and the high number of deaths linked with Advanced HIV Disease (AHD). This was proposed after conducting a study in rural Tanzania involving over two thousand participants between 2013 and 2019. The study aimed to assess the persistent burden of AHD and the impact after adopting World Health Organization (WHO) “Test and Treat” guidelines.

“Our study comprehensively describes the burden, characteristics, and outcomes of AHD in rural Tanzania and is representative for resource-limited settings in Sub-Saharan Africa,” the scientists noted in their paper published in the Open Forum Infectious Diseases journal on December 16, 2022.

The six-year study was conducted by Linda Stöger and Emilio Letang from The Barcelona Institute of Global Health (ISGlobal); Andrew Katende, Herry Mapesi, Maja Weisser and Aneth Kalinjuma from Ifakara Health Institute; Liselot van Essen from Amsterdam University Medical Center; Thomas Klimkait and Manuel Battegay from the University of Basel, Switzerland. 

“Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of loss to follow-up (LTFU) are urgently needed to reduce morbidity and mortality,” recommended the scientists.

These recommendations reflected the findings that showed more than 50% of people with HIV (PWH) enrolled in the study still had AHD at diagnosis even after the national implementation of “test and treat” guidelines.

“The distressingly high burden of AHD in this rural Tanzanian cohort, which remained high despite the treat-all guidelines, is representative of resource-limited settings throughout SSA,” the scientists noted.

“Recent WHO guidelines need to be evaluated for their effectiveness of reducing the burden of AHD and AIDS-related mortality in Sub-Saharan Africa,” they added.

The study was conducted in Kilombero districts in Morogoro and included 2,493 participants diagnosed with HIV aged 15 years and older. The participants were enrolled between January 1, 2013, and August 16, 2019, at the Kilombero Ulanga Antiretroviral Cohort (KIULARCO) – a single-site, prospective cohort of PWH. KIULARCO is based at the Chronic Diseases Clinic of Ifakara (CDCI), within the Saint Francis Referral Hospital (SFRH) in Ifakara.

In October 2016, the Tanzanian National AIDS Control Programme took up the WHO “test and treat” guideline from 2015 recommending ART for all PWH. Results of 2 clinical trials informing these guidelines showed that early versus deferred initiation of ART was beneficial, leading to a reduction in AIDS-related morbidity and mortality. However, the burden of AHD remained high despite the treat-all guidelines.

Of the 2,493 PWH, 62.2% had AHD at diagnosis. There was a decrease in the proportion of PWH presenting with AHD – 66.8% before vs 55.7% after the national implementation of WHO “test and treat” guidelines in 2016.

“Addressing AHD from a public health approach through providing access to the right diagnostic tools and treatment regimens and implementation of differentiated care interventions such as the existing WHO guidelines for AHD could significantly reduce the still unacceptably high AIDS-related morbidity and mortality and pave the way to end AIDS by 2030," they said.

Other notable key findings from the 6-year study included a high contribution of AHD to mortality and loss to follow-up (LTFU). One in 5 patients who enrolled in care with AHD experienced death or LTFU within 6 months. The scientists suggested “Improved linkage to care and targeted adherence support” in order to reduce the persistently high proportion of unfavorable outcomes.

About Advanced HIV Disease (AHD)
Advanced human immunodeficiency virus (HIV) disease (AHD) – defined by the World Health Organization (WHO) as having a CD4 cell count <200 cells/µL or clinical stage 3 or 4 at presentation to care – constitutes a major obstacle to the Joint United Nations Programme on HIV/AIDS’ (UNAIDS) goal of ending AIDS by 2030. AHD is associated with high morbidity and mortality, high costs for the health system, and increased risk of severe opportunistic infections (OIs), which – without timely diagnosis and treatment are often lethal.

>> Link to full publication: https://doi.org/10.1093/ofid/ofac611 

>> Read other Ifakara publications here: https://ihi.or.tz/publications/journals-paper/