By Kenneth Mwehonge

First, I would like to commend the Government, through Ministry of Health and Uganda AIDS Commission; the Health Development Partners, particularly PEPFAR and the Global Fund; and the non-state actors who are contributing to the national response to HIV.

Every one of us has contributed to the remarkable progress achieved in the fight against HIV and AIDS at different levels. HIV treatment has expanded and new infections have reduced. More than ever, it now looks possible to end AIDS by 2030. We have all the tools we need to end AIDS as envisaged in the global Sustainable Development Goals (SDGs). But this is if we all confront all the inequities and remaining hurdles – especially the high prevalence of advanced HIV disease (AHD).

The World Health Organization (WHO) defines advanced HIV disease as CD4 cell count below 200cells/mm3 or WHO stage 3 or 4 in adults and adolescents. They largely consist of individuals who present late for treatment after living with untreated HIV infection for long; those who previously fell out of care; and those whose antiretroviral treatment is no longer efficacious due drug resistance.

All HIV-positive children below five years are also considered to have AHD because of their weak immune system.

AHD is a serious problem. The latest Global AIDS update by UNAIDS shows that 650,000 people died in 2021 due to AIDS-related causes – one death per minute! Most AIDS-related deaths are due to AHD.

Whereas, Uganda has made significant progress in the screening and management of AHD, the burden among newly diagnosed is still significantly high. National program data for 2021 show that of the estimated 126,833 people who were newly enrolled on HIV treatment, 53,088 (42%) had a CD4 testing, and that of these 12,975 (24%) presented with CD4 less than 200 cells/mm3 at the time of HIV diagnosis, and thus, had AHD.

People with AHD are at high risk of death, even after starting antiretroviral treatment (ART). This risk increases with decreasing CD4 cell count.

The most common causes of severe illness and death in people with AHD are tuberculosis, cryptococcal meningitis, and severe bacterial infections.

To reduce illness and death of people with AHD, WHO recommends offering a package of interventions including screening, treatment and prophylaxis for major opportunistic infections, rapid ART initiation, and intensified adherence support interventions. The AHD package aims to widen access to key medicines and diagnostics to manage the most common causes of illness and death.

With support from donors, Uganda has made significant progress in the screening and management of AHD, but we still have many gaps which we must close to achieve the declared global and national goals. We need to take initiative as a country. The response to AHD is mainly supported by donors who are investing in commodities to diagnose and treat AHD and opportunistic infections, including CD4 testing for newly identified or previously lost clients, cryptococcal antigen, TB-LAM, cotrimoxazole, and fluconazole.

To more robustly and successfully confront disease progression and the key causes of death (tuberculosis [TB], cryptococcal disease) in people living with HIV (PLHIV), the recommended package of care, together with models of care empowering PLHIV and facilitating treatment adherence, are needed at the primary health care level. These will assist service providers, civil society and governments in their efforts to control HIV and AIDS.

Ministry of Health needs to expedite the review the HIV/TB treatment guidelines to accommodate the newer, evidence-based protocols for use of AmBisome as a single high dose accompanied by Flucytosine for two weeks for the treatment of cryptococcal meningitis.

Ensure there is enough medicines for management of HIV and AHD should be eliminated, and measures to minimize interruptions in treatment put in place. Critically, there is urgent need for a national commodity quantification of needs.

While CD4 test results are no longer needed for initiation to ART, baseline CD4 count remains the best diagnostic tool to assess a person’s immune and clinical status. It is essential for determination AHD status and it is the gateway the AHD recommended package of services.

Unfortunately, access to CD4 test services is low due to shortage of CD4 machines. CD4 is essential for diagnosing especially asymptomatic AHD as studies have shown that clinical staging/symptom screening on its own misses half of people with AHD at entry and re-entry into care.

Furthermore, CD4 can also help guide clinical decisions in PLWHAs whose ARVs are failing to control their virus or who have disengaged from treatment for some time. The use of point-of-care semi-quantitative CD4 tests that are available and affordable can identify PLWHA with advanced HIV disease (CD4<200) and therefore there is need for government to introduce package of care that includes prevention and screening tools for cryptococcal meningitis and TB. 

Rapid initiation of ART in people with AHD (defined as initiation of ART within seven days from the day of HIV diagnosis) is critical in reducing illness and the risk of death, just as is the need to screen, identify and treat opportunistic infections, particularly TB, Cryptococcal meningitis and severe bacterial infections.

Unfortunately, the capacity to screen for opportunistic infections in AHD is wanting. Screening is the assessment for the identification of a disease prior in an individual who is not presenting a complaint for that particular condition. The cryptococcal antigen can be found in the body weeks before symptoms of meningitis. Point-of-care rapid cryptococcal antigen tests are easy to administer (via venous blood or finger-prick) and are affordable. 

Timely screening and provision of fluconazole after a positive test is essential given the median time to development of CM following a CraG positive test is just 22 days.

For example, one study has found that treatment of asymptomatic Cryptococcal antigenaemia reduces progression to Cryptococcal meningitis with a 28% reduction in mortality among people presenting with AHD.

To fast-track progress towards ending HIV by 2030, the is need to scale-up of the management services for AHD to lower health facilities, including district hospitals, with lower-level health facilities providing screening, identification, and referral of patients with cryptococcal meningitis to higher facilities for specialist management.

Ministry of Health and HIV implementing partners should prioritize facilitation of community health workers to do intensive follow-ups of clients with AHD and guarantee the recommended package of interventions to reduce illness and death of people with AHD.

The writer is the Executive Director, HEPS-Uganda, a coalition for Health Promotion and Social Development.