BACKGROUND: AHD refers to people living with HIV with CD4 <200 cells/mm³, WHO HIV Stage 3/4 , or age below 5 years. In India, 35%-40% of people living with HIV register in care with CD4<200 cells/mm³ and are more susceptible to OIs like CM. To address this, the National AIDS Control Program (NACP) included AHD management packages of care in National guidelines in 2021. However, these packages are yet to be adopted at ART centres. In September 2022, the CM AHD care package was piloted at a Centre of Excellence in Delhi to inform national implementation via documented learnings and create standard operating procedures.
DESCRIPTION: Cryptococcal antigen lateral flow assay (CrAg LFA) and CM medications (fluconazole, flucytosine, L-AmB) were donated to the facility. Operational protocols and reporting systems were created, and healthcare workers were trained. Adults with AHD were tested using CrAg LFA, and accordingly given CM management/prophylaxis. Prevalence, uptake, health outcomes, and implementational challenges were documented utilizing aggregate data reported by the facility. Within four months, 1,504 people living with HIV underwent CD4 testing, of whom 255 (17%) had CD4 <200 cells/mm³. 122 (48%) of these 255 people with AHD were screened via Serum CrAg LFA, with 2 testing positive and receiving fluconazole prophylaxis.
LESSONS LEARNED: Linking people with CD4<200 cells/mm³ to CM screening was challenging due to long turnaround times (TAT) of CD4 tests, inability to schedule a quicker revisitation, and difficulty tracking people with pending tests during visitation. For mitigation, tracking mechanisms were strengthened by distinguishing AHD records using stickers and separate stacks, and assigning staff roles for client-tracking. Pre-test counselling was improved to encourage faster screening. AHD-tracking line lists were created to optimize reporting and ensure follow-up.
CONCLUSIONS: While the pilot is ongoing, preliminary data and learnings suggest that differentiated care for people with AHD in India would be beneficial. The national scale-up of the recommended AHD package should be accompanied by capacity building, defined modus operandi, incorporation of AHD metrics in national reporting systems, and procurement of optimal commodities. Additionally, strategies to reduce TAT of CD4 testing and optimize physical and virtual client tracking should be explored.

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