MSF: High numbers of people dying from AIDS in sub-Saharan Africa

Global attention needed to prevent and treat AIDS in antiretroviral era, with 50% of hospital admissions in MSF hospitals already on treatment and showing clinical signs of failure

Tuesday, July 25, 2017 — An unacceptably high number of people continue to develop and die of AIDS[1]-related diseases across sub-Saharan Africa. They remain left out of the global HIV response without access to treatment that prevents AIDS or the medical care they need, says international medical humanitarian organisation Médecins Sans Frontières / Doctors Without Borders (MSF).

In MSF’s briefing paper “Waiting isn’t Option: Preventing and Surviving Advanced HIV[2]” , data from MSF-supported hospitals presented at the International AIDS Society (IAS) Conference on HIV Science in Paris today, highlights that in MSF-run and MSF-supported hospitals in Democratic Republic of Congo (DRC), Guinea, Kenya and Malawi, people arrive with such severe immune failure that overall mortality for patients presenting with AIDS is between 30-40%. Almost one-third of those deaths occur within 48 hours.

The main causes of illness and death are due to treatment failure or interruption and late diagnosis leading to delayed treatment. 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. “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,” says David Maman, MSF Epicentre epidemiologist.

At community level, MSF population surveys also show that a proportion of people living with AIDS in communities in southern and eastern Africa remain untested and untreated. Around 10% of people living with HIV in districts of Malawi, Kenya and South Africa had AIDS, of which 47% had never received testing or treatment. “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,” says Gilles van Cutsem, MSF HIV Advisor.

Clinicians, including from MSF, have increasingly voiced concern over the lack of attention and means going towards the prevention and treatment of AIDS across Africa. The World Health Organisation (WHO) yesterday issued its first ever guidelines for the treatment of AIDS in low-resource settings. While this is a positive step forward, MSF calls for the urgent implementation of the guidelines with additional measures to address potential drug resistance and treatment failure.

Key interventions urgently needed to prevent and treat AIDS include the rapid rollout 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. MSF is also 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[3].

MSF is also concerned <www.msf.org/sites/msf.org/files/3_volets_rapport_financement_iads2-lh-4-print.pdf> that the situation will only be exacerbated as funding for the global HIV response continues to stagnate. Anticipated cuts in US funding to the Global Fund (17%) and PEPFAR (11%) from 2018 onwards will see many countries facing further grant restrictions. Shrinking funding envelopes and the need to preserve ART purchases will imperil community responses, including targeted testing and improved treatment literacy and adherence, while starving essential investments needed for health workers, laboratory and diagnostics.

“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,” says Mit Philips, MSF Health Policy Advisor.

ENDS

MSF currently supports over 230,000 PLHIV on ART in 19 countries, with a focus on free quality care, including test & treat approaches, improved adherence support and differentiated models of care.

MSF directly provides or supports the provision of free hospital-based care for the treatment of AIDS in four hospitals in sub-Saharan Africa. In Homa Bay district hospital (200 beds) and referral health centres in Kenya, MSF supports and trains medical staff and provides medical equipment, laboratory support and drugs to improve the treatment of opportunistic infections (OI). In the Nsanje district hospital (200 beds), Malawi, MSF is training medical staff to improve diagnosis and clinical management of HIV/AIDS patients, while increasing laboratory services, pharmacy support and supplies of OI treatment. MSF runs a specialised AIDS care unit in Donka Hospital (31 beds) in Conakry and in Kabinda Hospital (42 beds), Kinshasa, DRC and supports Roi Baudoin Hospital, also in Kinshasa. These centres work with peripheral health centres to improve patient referrals and provide hands on training to improve the overall quality of care for HIV/AIDS patients. In all HIV projects, MSF teams are developing and implementing packages of diagnostics and treatment for HIV/AIDS, along with improved treatment literacy and adherence support.

[1] Acquired Immune Deficiency Syndrome (AIDS) is defined as a CD4 count of less than 200 or WHO clinical stage 3 or 4.

[2] Advanced HIV is synonymous with Acquired Immune Deficiency Syndrome (AIDS).

[3] MSF’s report ‘Les Négligés de L’infection au VIH’ <https://issuu.com/msffr/docs/msf_kinshasa_report_digital> also released at IAS, shows the lack of referral-based hospital care for treating AIDS in Kinshasa, Democratic Republic of Congo (DRC).

Homa Bay, Kenya: Winnie, 25 years, tested HIV positive in 2015 and prescribed antiretrovirals. For two years, she was referred to numerous health facilities which made a proper diagnosis and treatment difficult. She was recently admitted for severe vomiting and diarrhoea. She was married but now lives with her mother. <br/><br/>Studies show that 25% of people in HIV care will interrupt their treatment at some point, for some reason, for a few days to several months. Photographer: Patrick Meinhardt
Homa Bay, Kenya: Medical staff in the tuberculosis (TB) ward in MSF-supported Homa Bay hospital, where AIDS accounts for 50% of all admissions. TB remains the leading cause of death among AIDS patients, followed by cryptococcal meningitis and toxoplasmosis, all difficult to treat without effective, accessible drugs and trained medical care. Photographer: Patrick Meinhardt
Homa Bay, Kenya: John, 40 years, was diagnosed with HIV in 2009 and started taking antiretrovirals immediately. He has been having diarrhoea for three weeks and lost a lot of weight before coming to Homa Bay hospital. <br/><br/>In MSF’s report “Waiting isn’t Option: Preventing and Surviving Advanced HIV” released in July 2017, MSF has called for the urgent implementation of new WHO guidelines to treated AIDS in low-resource settings with additional measures to address potential drug resistance and treatment failure. Photographer: Patrick Meinhardt
Homa Bay, Kenya: Zipporah, 33 years, was tested for HIV in 2016 but started taking antiretrovirals in February 2017 because she was afraid of the treatment. She has Kaposi Sarcoma, a form of cancer which occurs in late stages of HIV infection and will start chemotherapy soon.<br/><br/>In Homa Bay hospital, MSF supports the Kenyan Ministry of Health in providing comprehensive HIV services, including specialized hospital care for AIDS. Photographer: Patrick Meinhardt
Nsanje, Malawi: Misheck, 29 years, from Mozambique come to Malawi for work. After one month, he had a malaria attack. During his stay at Nsanje district hospital, he was diagnosed HIV positive with severe immune failure. <br/><br/>“I am feeling a bit better but I still cannot move. When I get better, I plan to stay in Malawi because where I come from, stigma is very high towards people who are HIV positive like me. Here in Malawi, people support each other.” Photographer: Luca Sola
Nsanje, Malawi: Seleman, 62 years, comes from a remote village and is clinically unwell. “I went for an HIV test at a health centre because I frequently fall sick. They found me with HIV. But I don’t believe the results are true. So I came to the hospital, I think they will tell me the truth.”<br/><br/>A second test confirmed that Seleman is HIV positive but he is still not convinced by the results. Photographer: Luca Sola
Kinshasa, DRC: A patient* admitted to MSF’s AIDS unit who died of tuberculosis days after this photo was taken. <br/><br/>People arrive at the centre with such severe immune failure that 36% don’t survive the first 48 hours of treatment. Hospital care for these cases requires the speed and urgency of a trauma case. Photographer: Kris Pannecoucke
Nsanje, Malawi: Chrissy, 37 years, a mother of three was referred to Nsanje district hospital with late stage AIDS. She couldn’t talk or walk but is feeling better now. She has been on antiretrovirals for five years.<br/>In hospitals and communities across sub-Saharan Africa, people continue to die of AIDS, despite antiretroviral treatment being more widely available than ever. In Nsanje district hospital, HIV still accounts for 26% of all admissions and 54% of all deaths. Photographer: Luca Sola
Kinshasa, Democratic Republic of Congo (DRC): An MSF doctor osculates a patient’s lungs to check for abnormalities in MSF’s HIV unit, which provides the only free hospital care for AIDS in the country. In DRC, HIV affects under 2% of the population and is highly stigmatized. People living with HIV also face frequent stock outs of drugs and high costs of tests and treatment. Photographer: Kris Pannecoucke
Homa Bay, Kenya: John, 56 years, was diagnosed with HIV in 2015 and has been taking antiretrovirals ever since. He was admitted in Homa Bay hospital in July 2017 with back and chest pain, and needs assistance for most tasks. <br/><br/>Around 65% of AIDS admissions to the hospital have already been on antiretrovirals before, with 50% showing some form of treatment failure. Photographer: Patrick Meinhardt
Nsanje, Malawi: Simbazako, 19 years, undergoes radiography for tuberculosis in Nsanje district hospital, Malawi. He says: “I feel too much pain in my ribs. I take my ARVs without skipping even a day but my health is not improving as I had expected.” <br/><br/>MSF is working with medical teams in Nsanje district hospital to improve diagnosis and clinical care of AIDS, including imaging, laboratory and pharmacy support.  Photographer: Luca Sola
Homa Bay, Kenya: Moses, 46 years, has AIDS and cerebral palsy and requires nasogastric nutrition support as he cannot eat. He has been put on second line antiretrovirals and is being supported by his wife in Homa Bay hospital. <br/><br/>Each AIDS patient represents a tangled web of individual, community, cost and health system weaknesses that have prevented or interrupted effective lifelong HIV treatment. Photographer: Patrick Meinhardt