The HIV/AIDS crisis has been with us since the 1990s and represents one of the worst global pandemics in history with millions of lives lost. Today, nearly 1 million people die annually of HIV/AIDS, and there are nearly 2 million new infections annually, mainly in lower middle-income countries, such as in Africa.1 The HIV/AIDS Global response has forced resource-limited settings to establish health frameworks and programs for HIV care, but challenges remain for key population groups.
A U.S. program called The President’s Emergency Plan for AIDS Relief or PEPFAR was established in 2003 and represents the largest financial commitment from any nation for humanitarian aid.2 The Office of U.S. Global AIDS under the Unites States Department of State has committed bipartisan support for more than $85 billion and saved 20 million lives in 50 countries since PEPFAR began. PEPFAR partners with multilateral organizations, such as The Global Fund, The Joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). The World Health Organization is the global policy organization for developing guidelines for HIV prevention and treatment, and UNAIDS is a key partner in operationalizing those guidelines, helping countries implement them into their own HIV programs. UNAIDS works with countries on results monitoring and reporting to help track progress on defined milestones and targets, informing priorities and supporting data-driven and targeted implementation of programs.
To counter the health problem, UNAIDS, in cooperation with the WHO, have established country goals to overcome the HIV/AIDS pandemic by 2025, so AIDS can be erradicated by 2030 as part of a Global AIDS Strategy.2 Countries are measured by what is known as the UNAIDS 95-95-95 goals, formerly known as 90-90-90 goals. The goals represent percentages of people living with HIV who know their HIV status, have been treated with anti-retroviral therapy (ART), and deemed virally surpressed or unable to infect others. As of December 2019, 81% of people living with HIV know their status, 82% who know their status are on ART, and 88% of those on ART are virally surpressed.4 UNAIDS is chartered for providing global leadership for pandemic response, developing programatic approaches to support 95-95-95 goals, strengthening capacity for local governments to implement effective HIV/AIDS national control responses to reduce inequalities that drive the AIDS epidemic. The UNAIDS Global AIDS Strategy identifies where, why and for whom the HIV response is not working. Despite progress made, AIDS remains a global health crisis that requires continued emphasis to achieve the 2025 goals.
Empowerment of key populations
Inequalities, such as stigma, discrimination and criminalization, are the most significant factors preventing progress against HIV/AIDS and underpinning populations who avoid HIV care that results in deadly advanced HIV disease. This includes the majority of people with new infections living in vulnerable conditions that preclude access to healthcare. Central to the disparities that drive new infections and advanced HIV disease are societal and structural factors for human rights that diminish access to HIV services. Key populations of people living with HIV are those most affected by human rights disparities, which hampers their access to healthcare services. The UNAIDS Global AIDS Strategy involves empowering communities to reach key populations at the forefront of HIV/AIDS response. The strategy focuses on driving results in 10 areas at the community level: HIV prevention, HIV testing and treatment, vertical HIV transmission, community led responses, equal human rights, gender equality, emphasizing youth, fully funded HIV community response, integration of HIV services into local health-system and humanitarian settings and pandemics.
The WHO has recognized that key populations are most in need for HIV care. As a result, new guidelines for advanced HIV disease or AIDS have been establish by the WHO.4 The WHO guidelines call for patients with CD4 counts less than 200 cells/µL to be considered at an advanced stage HIV disease. Understanding this important baseline of CD4 is critical to monitor patients for risks of opportunistic infections, such as tuberculosis (TB) and deadly respiratory infections. The revised 2017 WHO guidelines also call for baseline CD4 tests for new patients entering HIV care and for those patients who fail first or second line treatments or are re-entering HIV care. The use of CD4 testing is the gold standard method to assess immunological function or identify immunological failure.
Advancing service access, integration and scalability
Programatic partnerships are forged for implemenation to drive changes at the community level within countries with high burdens of disease. One of the most comprehensive frameworks for HIV/AIDS response has been the differentiated service delivery (DSD) network implemented by ICAP Global Health at Columbia University Mailman School for Public Health and the Coverage, Quality and Impact Network (CQUIN).5 The ICAP DSD networks leverage care for HIV/AIDS, other infectious diseases and non-communicable diseases in more than 30 countries. The DSD framework is a foundation for advancing health access in resource limited settings and strengthening health systems in a scaleable way. The DSD network is consistent with UNAIDS Global AIDS Strategy to have impact at the community level because the program is designed for greater access to care and integrated HIV services.
Among other programs supported, ICAP provides population-based household surveys in resource limited settings to assess HIV impact within communities. Recent evidence supports unacceptably high rates for HIV among key populations, such as young women and people 20 to 30-years-old.6 This suggests programatic gaps within communities to reach key populations, structural policy barriers for access to HIV care, and a need for client-centered approaches, such as DSD. People living with HIV have a diverse set of circumstances that necessitate an individual approach for HIV care. The DSD approach achieves flexibility for patient variations based upon what is required for a patient, where services are provided, the frequency of HIV services required, and who is providing the patient services. The DSD model has proved successful since implementation in 2017 and endorsed by partners, such as the WHO and PEPFAR.
Life threatening opportunistic diseases
The SARS-COV-2 pandemic has disrupted the progress towards meeting the 95-95-95 goals and represents another painful lesson for the extreme health disparities experienced for people living with HIV in lower middle-income countries. Lockdowns, as well as availability of testing and vaccines, have hampered health services, especially for people living with HIV and those in advanced stages of HIV.7 Governments in African countries imposed restrictive measures that included social distancing to prevent healthcare system overcrowding and depletion of medical supplies and resources.
Despite these challenges, health systems in lower middle-income countries showed resilience in overcoming decreases in HIV services in January through June of 2020, according to data provided by the Clinton Health Access Inititative 2021 mid-year report.3 They achieved those results by using telemedicine to continue delivering essential healthcare services.7 HIV health services, such as testing, ART administration, male circumcisions and female condoms, rebounded in the latter months of 2020. Still, there are hard to reach populations of people living with HIV in lower middle-income countries that hamper progress toward 95-95-95 goals.
Patients with HIV/AIDS are high risk when infected with SARS-COV-2, compounding health inequities for key populations and those hard to reach individuals requiring care. Fortunately, key programs for PLHIV during SARS-COV-2 pandemic, such as ART, Oral PrEP and testing, have shown resilience. This has been driven by virtual telemedicine adapted to the circumstances of COVID disruptions. Still, there are barriers and resistance that prevent full scale adoption for telemedince in lower middle-income countries.8 Despite the challenges, health systems maintained resilience for HIV care, but restrictions have caused pronounced inequalities to healthcare access, putting hard-to-reach populations at greater risk.
The WHO has put measures in place to prioritize hard-to-reach populations with greater access to point of care testing (POC) and increased supplies of ART for patients, such as pregnant women, infants, those with advanced HIV disease and co-infections.9 Countries in high burden HIV/AIDS settings are implementing more POC testing for diagnosis, providing up to six months of ART supply for patients and targeting those who are suspected of failing first line treatment.
The challenge for those living with HIV is not just to treat them with antiviral therapies — but to understand exactly how far their immune system has been compromised. Otherwise, they become susceptible to additional life threatening, opportunistic diseases. It is, therefore, critical that there is a way of identifying immunocomprised patients.
Identifying immunocomprised patients
Once a person is infected with HIV, the virus begins to attack and destroy a special type of white blood cell, called CD4. These cells play a major role in protecting the body from infection. Counting the number of CD4 cells in a patient’s blood is the most accurate way of monitoring how well the immune system is working and predicting the progression of HIV. The WHO has taken steps to explain the importance of counting CD4 cells by issuing three new guidelines to encourage best practices, explaining under which circumstances it is essential to know a patient’s cell count, as well as their viral load.4,9,10 The stages that the WHO has established to evaluate patients are clinical stages one, two, three, and four. A patient with advanced HIV is defined as clinical stage three and four and at risk of an opportunistic fungal infection or requiring prophylactic therapies. Relying solely on clinical staging can miss 60-70% of patients with low CD4 counts, as they may not manifest clinical symptoms, leading clinicians to place them in a lower clinical stage than is warranted.3 Used in conjunction with CD4 counts, these stages stratify patients as high or low risk for developing opportunistic infections. Patients with a cut-off above 200 cells/µL are at reduced risk, and below 200 cells/µL puts them at a higher risk for developing opportunistic infections.4
The gold standard: CD4 cell count
The 2016 and 2017 WHO guidelines provide guidance on the diagnosis of human immunodeficiency virus (HIV) infection, the care of people living with HIV and the use of antiretroviral drugs for treating and preventing HIV infection.4,10 While these guidelines recommend lifelong antiretroviral therapy, regardless of CD4 cell count (“treat all policy”) and analysis of viral load as the preferred monitoring approach, they also provide clear guidance on the indispensable role of CD4 in assessing baseline risk of disease progression, particularly for individuals presenting with advanced disease, decisions regarding starting and stopping prophylaxis for opportunistic infections, and prioritization decisions regarding ART initiation in settings where universal treatment is not possible. CD4 cell count measurement may also be important for people who are failing ART.
People with advanced disease are defined as those presenting to care with a CD4 count below 200 cells/µL or WHO disease stages 3 and 4. The package of care for these people should include the following:10
- Rapid initiation of ART (once the risk of immune reconstitution inflammatory syndrome is ruled out)
- Systematic screening for Cryptococcus antigen
- Screening and treatment for TB or isoniazid preventive treatment as indicated
- Screening for toxoplasmosis and Co-trimoxazole prophylaxis
- Intensive follow-up
Measures such as WHO guideline recommendations will continue to protect those patients under severe risk for SAR-COV-2 disruptions for care and resulting opportunistic infections if guidelines are followed.
- UNAIDS, (2021), Global AIDS Strategy 2021–2026: End Inequalities. End AIDS. https://www.unaids.org/en/resources/documents/2021/2021-2026-global-AIDS-strategy?utm_source=UNAIDS+Newsletter&utm_campaign=fda49f22d9-20210325_PR_global-AIDS-strategy-2021-2026&utm_medium=email&utm_term=0_e7a6256e25-fda49f22d9-114169641. Accessed August 2, 2021.
- U.S. Department of State, (2021). The United States President’s Emergency Plan for AIDS Relief. https://www.state.gov/pepfar/. Accessed August 25, 2021.
- CHAI, (2021) HIV Mid Year Market Memo, Clinton Health Access Initiative. https://www.clintonhealthaccess.org/hiv-mid-year-market-memo-2021/. Published June 3, 2021. Accessed August 25, 2021.
- World Health Organization (2017), Guidelines for managing advanced HIV disease and rapid initiation of anti-retroviral therapy. WHO, Geneva. Ver 6, pages 35-37.
- Grimsrud A, Bygrave H, Doherty M, et al. Reimagining HIV service delivery: the role of differentiated care from prevention to suppression. J Int AIDS Soc. 2016 Dec 1;19(1):21484. doi: 10.7448/IAS.19.1.21484.
- Birx D, Zaidi, Irum Z. Forward: Measuring progress toward epidemic control. Acquir Immune Defic Syndr.. 2021 Aug 1;87(Suppl 1):S1. doi: 10.1097/QAI.0000000000002700.
- Chitungo I, Mhango M, Dzobo M, et al. Towards virtual doctor consultations: A call for the scale-up of telemedicine in sub-Saharan Africa during COVID-19 lockdowns and beyond. Smart Health. 100207, ISSN 2352-6483. doi.org/10.1016/j.smhl.2021.100207.
- Mars M. Telemedicine and advances in urban and rural healthcare delivery in Africa. Prog Cardiovasc Dis. Nov-Dec 2013;56(3):326-35. doi: 10.1016/j.pcad.2013.10.006.
- World Health Organization (2021), Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring: WHO, Geneva.
- World Health Organization (2016): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach – 2nd ed., page 241.