Who is the severely ill HIV patient in

Who is the severely ill HIV+ patient in 2017? Defining advanced HIV Stephen Wanjala, MSF France Kenya IAS 2017 Satellite Symposium 23 rd July 2017 Waiting Isn’t an Option

Meet M. O. B • • • 32 year old Male Weight loss, poor appetite, cough, diarrhea Married, farmer, denies drinking or smoking First diagnosed in 2010, his last recorded CD 4 =>99, date unclear On ART since 2010; an NNRTI based regimen Denies history of TB Rx Severe wasting - BMI 16. 1, Height 176, weight 50 Able to stand Vitals: Temp 35. 7, BP 95/53 No resp. distress, no jaundice, not dehydrated, pale, no localizing signs POC Tests: • CD 4 – 15, • Hb - 4. 2 g/dl, • Neg: HBV, HCV, Urine LAM • Pos: SCRAG, CSFCRAG Other Labs & imaging • Viral load 76, 248, abnormal LFTs, elevated Creatinine • Normal CXR Dx: Cryptococcal Meningitis/Pneumonia/Acute Kidney Injury/HIV Waiting Isn’t an Option

Meet S. A. O • • • 30 year old female Weight loss, cough, general weakness Married, house wife, denies drinking or smoking HIV positive since 2009; Last cd 4 194 (2014), last VL 70, 000 (2014) On an NNRTI based regimen since 2012 Denies previous TB treatment Severe wasting - BMI 16. 8; Height 162, weight 44 kg Temp 35. 6, BP 80/50 Present: Pallor; Absent: Jaundice, dehydration Not in resp. distress, No focal signs Dx: Pulmonary TB/Severe Anemia/HIV Waiting Isn’t an Option POC Tests: • CD 4 48, Hb 5. 5 g/dl • Neg: HBV, HCV, Scrag, Malaria • Pos: TB Lam Other Labs & imaging • Abnormal: LFTS, Creatinine, CXR • Positive: Xpert MTB

and many more…HB IPD Study • 63% (95% CI; 57. 7 – 68. 2)of patients had CD 4 below 200 • 73. 7% HIV +ve admissions => WHO stage 3 or stage 4 • 9. 3% of all patients had a BMI<16 kg/m², but 22. 3% could not stand • Men were more likely to be severely immunosuppressed (CD 4<100 cells/μL; 27. 2%) than women (18. 2%, p<0. 01). Waiting Isn’t an Option

and many more…HB IPD Study • 46. 8% of the total HIV+ patients were on treatment for more than 6 months (Median time-on-ART 44. 1 months, IQR 18. 4 -90. 5) – Among these 79% in WHO stage 3 (43. 9%) and 4 (35. 1%), defining clinical treatment failure – 45. 3% had a CD 4<100 cells/μL – Of the 54 patients on ART for more than 6 months who had a VL performed, 34 (63. 0%) had a Viral Load>1, 000 copies Waiting Isn’t an Option

Our severely ill patient… • • • ART experienced; likely still on first line Severely wasted Very low CD 4, High viral load Multiple pathologies/opportunistic infections Likely failing first line ART At a high risk of mortality Waiting Isn’t an Option

A difference from the past? • Previously we saw late presenters in the context of limited access to ART • Mostly were ART naïve • Similar clinical syndromes A significant proportion of advanced illness is now associated with TREATMENT FAILURE Waiting Isn’t an Option

THANK YOU Waiting Isn’t an Option

MSF HIV/TB Clinical Guide

Need to be quick !! 25 to 35 % death within next 48 hrs

Viral load : when/who to accelerate switch to 2 nd line At PHC level • 2 nd line switch if per standard algorithm • Triggered VL /referral if unstable At referral level • after 1 VL>1000 - if CD 4<100 If pregnant • Empirical – Clinically failing , stage IV – CD 4 < 100 – No VL result available within 3 days -> Switch back if VL suppressed subsequently ?

MSF Research on Advanced HIV • Presented at IAS • Oral: Feasibility of using Determine-TB LAM test in HIV infected adults in programmatic conditions - Sekai Chenai Mathabire (Epicentre) Monday 24 July - 17: 45 -18: 00 - Maillot Room • Poster: Mycobacterium tuberculosis lateral flow urine lipoarabinomannan assay (TB-LAM) and cryptococcal antigen lateral flow assay (CRAG LFA) as screening among patients with advanced HIVdisease in Conakry, Guinea – Leonard Ndayisenga (MSF)– 25 July – 12: 45 • Poster: High proportion of virological failure and drug resistance among adolescents on first-line ART in Chiradzulu District, Malawi Birgit Schramm (Epicentre) Tuesday 25 July 2017 12: 30 -14 h 30 • Resistance Prospects • Resistance among ART experienced hospitalised patients with advanced HIV • New switch algorithms after 1 Vl for patients on NNRTI based 1 st line