95-95-95 Enhancing clinical care in advanced HIV disease & complex opportunistic infections

World AIDS Day 2024
95-95-95: Enhancing clinical care for people with advanced HIV disease and those with complex opportunistic infections

Over the past two decades, The President’s Emergency Plan for AIDS Relief (PEPFAR) has been at the forefront of the global fight against the HIV pandemic and has led interventions that have saved millions of lives and empowered many people living with HIV to continue to live quality lives. It is also notable that many countries in sub-Saharan Africa are making great progress towards the UNAIDS 95-95-95 targets for eliminating the pandemic by 2030. Central to the targets is the fact that no one should be left behind. It is against this backdrop that those who end up with advanced disease or complex intractable symptoms need further attention.

The recent HIV epidemic update for Uganda, based on PEPAFR Uganda 2023 statistics, shows that despite the advent of ART, HIV associated mortality remains a challenge with over 300,000 deaths recorded in adult people living with HIV and 3200 deaths among children. These are not small numbers, and the impact on families and communities is huge.

In patients with advanced disease, or those who experience severe opportunistic infections, complex symptoms and concerns have been documented, with the most common being TB, pain, gastrointestinal dysfunction, HIV-related cancers and mental health illnesses. Some of these symptoms occur in clusters which worsens the symptom associated distress. This segment of people living with HIV can benefit from palliative care to get their symptoms under control. There is substantial evidence to show that early palliative care improves symptom distress, quality of life, survival and general well-being of patients. It can, therefore, help with retention in care, adherence and viral load suppression. Ironically though, palliative and comprehensive chronic care are not well integrated into HIV services, which denies patients with complex symptoms and concerns and those with advanced disease the opportunity to access quality person-centred care that aligns with their specific needs and concerns.

To advance the 95-95-95 goals and the 10-10-10 goals , it is important to ensure that the multi-dimensional needs of all patients are met in a timely manner so as to optimise outcomes of care.

Pathways to integration palliative and comprehensive chronic care include training of the HIV health workforce in palliative, sensitisation about the complexity of needs and need for a multi-disciplinary approach to caring and effective and compassionate population and a need to refer patients for palliative and comprehensive care as needed. This alliance will not only optimise outcomes of care but will also strengthen referral pathways for early enrolment into care and ART initiation.

1. Rangaraj A, Connor S, Harding R, Pinto C, Chitembo L, Ford N. Advanced HIV disease and health-related suffering-exploring the unmet need of palliative care. Lancet HIV. 2023;10(2):e126-e33.
2. Burke RM, Feasey N, Rangaraj A, Camps MR, Meintjes G, El-Sadr WM, Ford N. Ending AIDS deaths requires improvements in clinical care for people with advanced HIV disease who are seriously ill. Lancet HIV. 2023;10(7):e482-e4.
3. Guidelines for Managing Advanced HIV Disease and Rapid Initiation of Antiretroviral Therapy. Geneva: World Health Organisation; 2017.