Advanced illness at HIV treatment start is dropping in some countries surveyed, still seen in a third of new patients

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The prevalence of advanced HIV among people beginning antiretroviral treatment has declined in eight of 10 resource-constrained countries surveyed, while median immune cell counts went up — indicating less weakened immune systems — in six countries, indicating improved access to testing and treatment, but still, about one third of patients starting treatment during the time tracked did not do so until their disease had advanced to a point indicating the need for additional specialized care. That’s the good news and the bad, from nearly 700,000 patient records across 10 low- and middle-income countries in Africa, the Caribbean and Southeast Asia, from 2004 to 2015, the good news highlighting progress, the bad news indicating how much more progress is needed for HIV care to be as effective and efficient as it could be. The findings were published Thursday in a U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.

Also concerning, the authors, led by Andrew F. Auld of the World Health Organization, note, is that while WHO has recently recommended additional testing and preventive treatment for patients with advanced disease because they are more vulnerable to opportunistic infections, 40 percent of the medical records reviewed did not record a baseline immune cell — or CD4 — count at all. The records, from nearly 800 facilities administering antiretroviral treatment in Haiti, Mozambique, Namibia, Nigeria, Swaziland, Tanzania, Uganda, Vietnam, Zambia and Zimbabwe, reflect widely different numbers of patients, and different time periods in each country. In Haiti, Mozambique, and Namibia, where patients records are monitored through centralized electronic systems, all patient records from 2004 to 2014 were reviewed, with 2015 included for Haiti as well. Selected samplings of facilities considered representative supplied records for more limited periods in other countries, including in Zimbabwe, where records reviewed reflected treatment initiations only from 2007 through 2009, Vietnam where only records from 2005 to 2009 were reviewed, and Uganda, where records from 2004 to 2009 were reviewed. Still, even the more limited records indicated improved and earlier access to treatment, with the percent of new antiretroviral treatment patients with advanced disease dropping from 84 percent to 75 percent in Zimbabwe, and from 89 percent to 60 percent in Uganda. Countries where more complete and recent spans of data were available showed more impressive improvements, including in Mozambique, where prevalence of advanced disease upon treatment initiation dropped from 73 percent to 37 percent, and in Haiti, where rates of advanced disease dropped from 75 percent to 34 percent.

While those figures give a glimpse of the progress possible in countries continuing to overcome high burdens of disease and limited resources, they also indicate the benefits of more countries adopting WHO guidelines to treat all people diagnosed with HIV when they are diagnosed, and to make HIV testing and treatment more widely accessible, lowering rates of sickness, death, and infection in the process, the authors note.

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