While an additional 2 million people are reported to be on antiretroviral therapy (ART), more needs to be done by all concerned to confront the killer infections driving AIDS death, starting with tuberculosis and cryptococcal meningitis.
"In MSF supported hospitals in the Democratic Republic of Congo, Guinea, Malawi and elsewhere, many deaths occur within 48 hours of admission,” said Dr Gilles Van Cutsem, leader of the MSF HIV/AIDS Working Group. “Patients arrive very ill, often with severe opportunistic infections such as tuberculosis, cryptococcal meningitis, or Kaposi's sarcoma. When they arrive, sometimes it's too late to save them. They might not have been diagnosed on time, or failed to get access to a life-saving treatment."
AIDS related deaths are primarily driven by delayed diagnosis, treatment interruptions and virologic and immunologic failure among HIV-treatment-experienced people.
The World Health Organization (WHO) estimates that more than 30% of people who start HIV treatment worldwide have advanced disease with severe immune suppression, which puts them at a very high risk for opportunistic infections and death. One in three deaths linked to AIDS is due to tuberculosis, while cryptococcal meningitis accounts for 15% to 20% of all AIDS-related deaths. Other serious opportunistic infections which contribute to AIDS-related mortality include pneumocystis, bacterial pneumonia, and sepsis. However, very little attention has been paid to the detection and management of people with advanced HIV, and access to diagnostic tests and treatment for many opportunistic infections is severely limited.
In the countries where MSF works, diagnostic tools such as the CD4 cell count, which is needed to diagnose advanced HIV disease, are often missing. TB-Lam and CrAg LFA, tests which provide quick diagnosis of tuberculosis and cryptococcal meningitis, also remain unavailable, particularly in primary health care settings where many people go first for their healthcare needs.
“If primary care clinics are not equipped and trained to detect advanced HIV, patients at risk will remain undetected and untreated; they will deteriorate until they are terminally ill. Then some will be referred to hospitals often missing the basic tools to manage them,” explains Dr Van Cutsem.
In 2016, the UN member states endorsed the goal of cutting AIDS deaths by 50% by 2020, to less than 500,000 per year. With just six months to go until this deadline we are far from achieving this target. AIDS deaths have only reduced from 800,000 in 2017 to 770,000 last year. UN member states also agreed to UNAIDS’s 90-90-90 targets where 90% of people living with HIV know their status, 90% of those tested HIV positive are on antiretrovirals and 90% of people on treatment have an undetectable viral load.
Earlier this year, MSF and the South African Department of Health demonstrated that it is possible to achieve the 90-90-90 targets and a possible reduction of incidence in Eshowe, KwaZulu Natal province in South Africa, with intensive community-based services linked to primary care facilities supported by training, mentoring and monitoring. While encouraging, Eshowe remains an exception and few other districts, provinces or countries are set to reach the 90-90-90 targets in 2020.
In particular, countries in the West and Central Africa region are facing a shortfall in international funding including for antiretroviral treatment scale up. It is urgent that these communities get the necessary resources and support to apply the lessons of community approaches of HIV testing and treatment - like in Eshowe.
"We cannot celebrate or talk of success while hundreds of thousands continue to die of AIDS every year because they do not access basic HIV care, either because they live in countries that are neglected, because they are part of neglected population groups, or because of policies that chose to ignore them. Preventing, detecting and treating advanced HIV and AIDS, demands more attention and funding, especially in low coverage settings such as West and Central Africa, and in neglected populations," said Dr Van Cutsem.
Governments, ministries of health, international agencies, donors and partner organizations must step up efforts and focus to reduce the number of AIDS-related deaths, with specific enhanced attention towards preventing, detecting and treating advanced HIV disease and AIDS.