Abstract
ABSTRACTBackground: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September–November 2012), (Chiradzulu (Malawi): February–May 2013) and (Eshowe (South Africa): July–October 2013). Eligible individuals 15–59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8–10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4–9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8–14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2–17.5) than women 7.5% (95%CI 6.6–8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7–2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3–2.1).Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.
Highlights
Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality
Since we did not have clinical data of individuals who participated in the studies, we considered all PLHIV with CD4 count
Proportion of adolescents aged 15–17 years old who refused to provide consent to participate in the study was slightly higher in Eshowe (South Africa) with 63/ 937 (6.7%) followed by 36/851 (4.2%) in Ndhiwa (Kenya) and 35/1066 (3.3%) in Chiradzulu (Malawi)
Summary
Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality. A substantial number of PLHIV continue to experience advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality [2]. Despite sharp increases in number of ART initiations, HIVrelated mortality has declined little over recent years [11] suggesting that even in the context of ‘treat all’, specific focus has to be directed towards patients with advanced HIV disease who are at highest risk of mortality. In order to reduce high HIV-related mortality and morbidity [2,12,13], the WHO released guidelines in 2017 for managing individuals with advanced HIV disease including their rapid initiation on ART [14]. In order to apply these recommendations effectively, we need to know the number and characteristics of people with advanced HIV to plan for their management and allocate resources appropriately
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