HIV Specialist - June 2021 - 23

and a few of the many challenges facing HIV
providers and their patients in Ethiopia.
Advanced HIV Disease
The burden of advanced HIV disease is
substantial across the developing world.
In Ethiopia, two out of every three people
diagnosed with HIV may have World Health
Organization (WHO) stage III disease or a CD4
count less than 200.9 Tuberculosis (TB) also
weighs heavily on patients with co-infection
being present in one out of every four patients.10
While the WHO has a recommended care
bundle for patients with advanced HIV disease,
there are often barriers to local implementation.11
For example, CD4 counts are considered
a basic element of care but large percentages
of patients enrolled in HIV programs may
not receive this testing despite well-validated
point-of-care tests.12 There are numerous
mechanisms that make routine CD4 testing unpredictable
including changes in funding priorities,
lack of reagents, lack of trained personnel,
or erratic utilities (e.g. power outages).
On review of our own data from Adama
during the early years of the WHO endorsed
test-and-treat policy, less than two percent of
patients had a CD4 count over a four-year period.13
An unintended consequence of this policy
at Adama led to shifts in funding allocation with
frequent supply shortages as well as de-prioritization
with the focus shifting to immediate ARV
initiation. However, patients with advanced
disease are at substantial risk for adverse outcomes
in areas where cryptococcal disease and
tuberculosis are endemic without appropriate
prophylaxis and carefully timed ARV.14-16
Through a recently developed partnership
between the Adama Hospital HIV clinic and
the Department of General Internal Medicine
at the University of Minnesota, we focused
on following the outcomes of and improving
adherence to WHO recommendations for the
management of advanced HIV. This package
consists of several interventions including
screening, treatment and/or prophylaxis for
major opportunistic infections and a focus on
the rapid initiation of ARV with careful consideration
of CD4 count at the time of care
engagement (Table 1). While these guidelines
are modeled on large studies with demonstrable
survival benefit, the real-world impact of
these guidelines is largely unknown.17, 18
Since the initiation of our program,
WWW.AAHIVM.ORG HIVSPECIALIST JUNE 2021 23
there has been a high acceptance rate of the
bundled care approach given that much of the
work-up can be done in a single day. This has
helped providers be more confident in differentiating
between which patients should be
recommended to start antiretroviral therapy
immediately versus those that should have a
deferred approach. Data collection is ongoing
and we expect to have results later this year.
While our approach strives to meet the guidelines
set forth by the WHO, there continue
to be limitations. For example, in patients
with symptomatic cryptococcal disease,
amphotericin cannot be locally sourced and
patients receive second line high dose fluconazole
despite the established superiority of
amphotericin.
First-Line Antiretroviral Therapy
While integrase inhibitor-based therapy for
HIV is nearly taken for granted in the United
States, dolutegravir was not fully endorsed
by WHO guidelines until 2018 and many
patients initiating ARV around the world
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HIV Specialist - June 2021

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