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WHO recommends package of tests, treatment and prevention for 'urgent need' people with HIV with low CD4 counts
Keith Alcorn, 2017-07-23 17:20:00
A new package of measures to ensure rapid initiation of
antiretroviral treatment and diagnosis of opportunistic infections has been
recommended by the World Health Organization (WHO) to reduce the still high rates of
death in people diagnosed with HIV at a very advanced stage of disease.
WHO says that people have advanced
HIV disease if they have a CD4 cell count below 200 cells/mm3, or
symptomatic HIV disease (WHO stages 3 or 4). People in these categories have a
very high risk of further disease progression or death and are in urgent need
of treatment. All children with HIV below the age of five are considered to
have advanced HIV disease.
Although 'test and treat' treatment guidelines have led to a
reduction in the proportion of people who start treatment at very low CD4 cell
counts from close to two-thirds in 2010 to around one-third in 2015, the
overall number of people who are starting treatment at low CD4 counts remains
high due to the overall increase in the volume of people beginning treatment.
People are also presenting for treatment with very advanced
HIV disease after having been lost from care or treatment previously, said Dr Eric
Goemaere of Medécins san Frontières (MSF). A majority of people presenting
late for treatment in South Africa are probably people who have fallen out of
treatment, not treatment-naïve patients, he told a WHO symposium.
What’s more, MSF has found that around three-quarters of all
hospital admissions at its clinics providing HIV care are of advanced HIV
patients who have been receiving antiretroviral treatment for some time,
suggesting that signs of virological, immunological or clinical deterioration
have been missed.
People presenting with advanced disease are at high risk of
death even after starting antiretroviral treatment because they usually arrive
at health care facilities with opportunistic infections. The
Reality study of preventive treatment for people with advanced HIV infection
found that deaths peaked in the first three weeks of the study, especially
among people not receiving the enhanced package of preventive treatment tested
in the study.
Among people with advanced HIV disease, tuberculosis (TB) remains
the biggest killer, accounting for around a quarter of all deaths, said Nathan
Ford of WHO. Cryptococcal meningitis, bacterial infections and pneumocystis pneumonia
account for more than half of the remaining deaths.
To address these risks, WHO is now recommending a package of
tests and interventions designed to ensure rapid treatment of HIV infection and
Treatment that can prevent the development of disease is not
being used to full advantage, despite a series of WHO recommendations over the
past few years. In particular, the implementation of isoniazid preventive
therapy to prevent TB is still patchy and rapid diagnosis of TB also needs to be
scaled up to save lives.
WHO also recommends that people with advanced disease should
start antiretroviral treatment immediately unless they have TB or cryptococcal
meningitis, in which case they should start treatment as soon as it is safe to
do so. Short-term worsening of symptoms – the immune reconstitution
inflammatory syndrome (IRIS) – may accompany a rise in CD4 cell count after
starting treatment so it is important to begin to bring these diseases under
control before beginning antiretroviral therapy.