Shortly before the world’s biggest bi-annual international Aids society Conference on HIV Science in 2017 – the ninth of its kind – kicked off in Paris, France, the news was mixed about access to life-saving treatment for HIV/Aids patients across the globe.

Unacceptably high numbers of severely ill people are presenting and dying of advanced HIV disease at numerous MSF-supported hospitals and districts in sub-Saharan Africa, the humanitarian organisation Doctors Without Borders (MSF) said on Tuesday.

This was in response to data released by UNAids late the previous week, which announced the 90-90-90 targets were having a noticeable life-saving impact worldwide. “The scales have tipped,” UNAids said in a statement – “19.5-million people (are) on life-saving treatment and Aids-related deaths (have) halved since 2005.”

Ironically, reports MSF, the high rate of deaths among those with advanced HIV may be, in part, related to unforeseen failures in the treatment of the disease – among these being growing drug resistance.

The good, the bad and the downright bleak

UNAids had been upbeat ahead of the conference. More than half of all people living with HIV (53%) now have access to HIV treatment and Aids-related deaths have almost halved since 2005, it said. In 2016, 19.5 million of the 36.7 million people living with HIV had access to treatment, and Aids-related deaths have fallen from 1.9-million in 2005 to 1-million in 2016. Provided that scale-up continues, this progress puts the world on track to reach the global target of 30-million people on treatment by 2020, it said.

“We met the 2015 target of 15-million people on treatment and we are on track to double that number to 30 million and meet the 2020 target,” said Michel Sidibé, Executive Director of UNAids. “We will continue to scale up to reach everyone in need and honour our commitment of leaving no one behind.”

The organisation released a report entitled Ending Aids: Progress towards the 90-90-90 targets, which gives a detailed analysis of progress towards these targets. According to the report, the region showing the most progress is eastern and southern Africa, which accounts for more than half of all people living with HIV. Since 2010, notes the report, Aids-related deaths have declined by 42%. New HIV infections have declined by 29%, including a 56% drop in new HIV infections among children over the same period.

In a statement, the UN called this “a remarkable achievement resulting from HIV treatment and prevention efforts that is putting eastern and southern Africa on track towards ending its Aids epidemic”.

MSF, however, took a dimmer view of the data. It said that while there had been progress, there was still substantial cause for concern. In November 2016, the organisation opened a third medical care centre treating advanced HIV/Aids in West and Central Africa. The centre was opened in response to an acute need in Guinea, MSF said, due to a lack of access to testing and medical care combined with a high incidence of HIV/Aids.

“Our medical staff in Guinea were seeing many acutely ill patients who had huge challenges in getting HIV treatment and regular tests for a medical fellow-up,” Ibrahim Diallo, MSF Head of Mission for Guinea, said at the time.

“By far the biggest obstacles are the high costs, getting specific drugs for advanced HIV, and huge stigma around HIV. Without regular treatment, people living with HIV can get very ill. We realised there was little-specialised hospital care for these cases in Guinea, which is why the [centre] was established.”

Medical staff, said the organisation, were seeing many acutely ill Aids patients who arrived at hospitals so ill that a third of them died within days of arrival.

Late in 2016, just 5% of Guineans had access to HIV testing, with less than 29% of people diagnosed with HIV getting treatment. “There are huge barriers to accessing HIV tests and treatment, including a national cost recovery system and drug supply issues that prevent wider roll out of antiretrovirals,” MSF said. Far more was needed in terms of prevention initiatives, it added.

Managing advanced HIV

On Tuesday, MSF issued a new statement calling for greater attention to the detection and management of people with advanced HIV. 

“In an era where antiretroviral drugs (ARVs) are widely available, in most regions, staff in MSF-supported hospitals specifically in Malawi, Kenya and the Democratic Republic of Congo (DRC), are still seeing people presenting with severe immune suppression (CD4 less than 200) – a condition putting them at high risk of contracting opportunistic infections (OIs) and mortality from Aids is between 30-40%,” the organisation said.

It acknowledged UNAids’ 2016 data on the successful implementation of ART, but said more could be done to decrease mortality. “Of the 36. 7-million people living with HIV globally, 19.5-million people have access to ART, yet 1 million people still died from Aids-related illnesses,” MSF added. “While increased access to ART has led to reduction of overall mortality over the last 10 years, these gains have been limited for those people with advanced HIV due to various reasons.”

These reasons include late diagnosis, and the high price of current treatments or diagnostics to address opportunistic infections like tuberculosis, cryptococcal meningitis, toxoplasmosis and pneumonia. Stigma also plays a role, MSF argued.

“People are still being diagnosed late. We need new ways to detect those left out, early on, before they arrive at hospital in often fatal condition or die at home without ever receiving care. Stigma and lack of information still remain high, leading to delayed treatment or no testing and treatment at all. This illustrates the need to complement increased antiretroviral coverage at community level with improved care for those on treatment for years,” said Gilles van Cutsem, MSF HIV Advisor.

But notably, there is a fresh paradox: in areas where HIV prevalence is low, access to testing and treatment may also be low, MSF said. Furthermore, in Southern and Eastern Africa, where ART coverage is higher, and UNAids data shows higher apparent success, drug resistance is also becoming higher, leading to treatment failure and fatigue. “Up to 60-80% of patients in MSF-supported hospitals have treatment failure in Southern Africa,” the statement added.

Moreover, the main causes of illness and death are due to treatment failure or interruption and late diagnosis leading to delayed treatment, the organisation added. Unlike in the early 2000s, when little treatment was available, more than 50% of Aids admissions at referral hospitals supported by MSF had already started antiretroviral therapy (ART), with many showing clinical signs of treatment failure, it said.

“Despite extensive access to antiretrovirals, there has not been the expected drop in late-stage presentations of HIV in developing countries. What’s different is that among people admitted to hospitals, the majority are already diagnosed and many have been on treatment for several years. In Kenya, in Homa-Bay, where antiretrovirals have been available for years, half of the patients hospitalised Aids cases show signs of treatment failure. We’re pushing to switch these patients to second-line antiretrovirals more rapidly,” said David Maman, MSF Epicentre epidemiologist.

MSF called for wide implementation of the new WHO guidelines for advanced HIV and strengthened hospital-based care, alongside reinforced methods to keep as many patients as possible under effective treatment at community, primary and secondary healthcare levels. “Policy makers, international organisations, ministries of health, donors and partner organisations in both high and low HIV prevalence settings must to increase investment and funding of new packages of care for neglected and vulnerable groups, as well as the registration and supply of affordable treatments for opportunistic infections,” the organisation said.

Towards 2030

Key interventions urgently needed to prevent and treat Aids include the rapid roll-out of “test and start”, CD4 baseline testing at ART initiation, routine viral load testing, point of care diagnostics for tuberculosis, improved treatment for cryptococcal meningitis, rapid switch to second-line ART for failing and advanced patients, and swift, effective and accessible treatment for opportunistic infections, activists added, calling for models of care geared towards prevention, treatment and support for patients with Aids, and free specialised hospital-based care free of charge for patients.

“Each patient presenting with Aids is a terrible testimony to the challenges to get timely access to test & treatment and to continue their ART uninterrupted. With global political will and funding for HIV on the decline, not only is the broader fight against the virus at risk go into reverse but specifically these patients arriving at hospitals sick with Aids will have any hope of reprieve snatched away,” said Mit Philips, MSF Health Policy Adviser.

South African Health Minister Aaron Motsoaledi reiterated the importance of ongoing treatment programmes. “We used to have 70,000 born every year HIV positive. Due to the very successful mother-to-child transmission (programme), that figure has fallen far below 6,000 from 70,000,” he said.

But as the conference – which runs until 26 July – continues, it remains to be seen whether calls against complacency internationally will be effective. The 2018 Trump budget has been at the centre of concerns that nearly a million people, mostly in Africa, could be deprived of life-saving HIV/Aids medication.

Meanwhile, research has shown that in six of 10 countries studied in Africa, Asia and Latin America, more than 10% of people starting antiretroviral therapies had HIV strains that were resistant to the most commonly used medications.

At the same time, HIV treatment is expected to increase by up to $650-million in the next five years if no action is taken to combat the trend of resistance. Costs of the HIV response are expected to peak at approximately $26.2-billion in 2020. DM

Photo: Living with HIV/Aids orphan children receive their antiretroviral HIV drugs from drug storage at Mercy Centre for HIV/Aids patients, Bangkok, Thailand, 04 May 2007.  EPA/RUNGROJ YONGRIT