Advanced HIV disease

WHO defines advanced HIV disease (AHD) as CD4 cell count <200cells/mm3 or WHO stage 3 or 4 in adults and adolescents. All children younger than five years of age are considered to have advanced HIV disease. This includes both individuals presenting to care who are antiretroviral therapy (ART) naive and those returning to care after interrupted treatment.

CD4 cell count testing, while no longer needed to initiate treatment, remains an essential tool for identifying people with AHD. All children younger than 5 years are considered to have AHD, given their heightened risk of disease progression and mortality.

People with AHD are at high risk of death, even after starting ART; this risk increases with decreasing CD4 cell count. The most common causes of severe illness and death are tuberculosis, severe bacterial infections and cryptococcal meningitis.

To reduce morbidity and mortality in people presenting with AHD, WHO recommends offering a package of interventions including screening, treatment and prophylaxis for major opportunistic infections, rapid ART initiation (1), and intensified adherence support interventions (2). The AHD package intends to widen access to key medicines and diagnostics to manage the most common causes of illness and death.

WHO has specific guidance for children and adolescents with advanced HIV disease and for the management of TB, cryptococcal meningitis, histoplasmosis, and skin and oral HIV-associated conditions.

(1) Rapid initiation is defined as within 7 days from the day of HIV diagnosis; people with AHD should be given priority for assessment and initiation.

(2) Intensified adherence support interventions include intensive/enhanced adherence counselling, home visits or phone calls, and home-based/palliative care.