BACKGROUND: Although the advanced HIV disease (AHD) care package reduces morbidity and mortality in people with AHD (WHO stage 3 or 4 and /or CD4 count <200 cells/µL or age <5 years), it is not fully implemented in India. We assessed the feasibility of implementing the complete WHO advanced disease management (ADM) package of care as part of routine HIV care under the programmatic setting in antiretroviral therapy (ART) centres of Mumbai.
METHODS: We implemented the ADM package in 17 ART centres from November 2020 to December 2021. ADH patients >9 years, both new to care and treatment experienced were enrolled. We trained the existing ART centres’ staff on identification of AHD patients, ADM package and patient flow. ADM package components included rapid ART initiation (within a week), Anti-TB treatment (ATT) initiation, cotrimoxazole prophylaxis, TB Preventive therapy [TPT, excluded active TB patients (n=280) and those completed TPT prior to enrolment (n=1186)] of negative TB screen, TB_LAM screening (excluded active TB patients), cryptococcal antigen (CrAg) assay (excluded children<10 yrs.), and ART adherence counselling. We used point of care test (POCT) for TB (LAM) and cryptococcus (CrAg) screening.
RESULTS: We enrolled 64% (2,804/4,334) of patients with AHD into ADM package of care using existing staff. Of the enrolled, 67% were males, median age was 43 years, median CD4 count was 137 cells/mm and 79% (2,217/2,804) were treatment experienced. 90% (528/587) of treatment new were rapidly initiated on ART. Nearly 86% (1,157/1,338) and 97% (2,733/2,804) received TPT and Cotrimoxazole prophylaxis respectively. Of the eligible 99% (2,508/2,524) and 96% (2,690/2,804) were screened for TB and cryptococcal infection by TB-LAM and CrAg assay respectively. 7% (171/2,508) were TB-LAM positive, and 92% (157/171) initiated on ATT. One percent (25/2,690) were serum CrAg positive, and 92% (23/25) were referred for CSF CrAg (1/23 positive). At the end of 12 months, 88% (2,485/2,804) enrolled in ADM package were alive.
CONCLUSIONS: Implementing of ADM package is feasible in routine setting with the existing patient flow without additional staff at ART centres. Availability of point of care tests demonstrated additional diagnostic and clinical management capabilities among patients with AHD.