FIGHTING AIDS: Open Letter to WHO to measure and report on HIV co-infections

FIGHT AIDS COALITION (FAC) OPEN LETTER TO WHO

5 November 2021

Dear Meg,

We are writing as the Fight AIDS Coalition (FAC) to put forward a set of requests regarding WHO leadership on the issue of advanced HIV disease (AHD)/AIDS and to provide feedback regarding the WHO Draft Global Health Sector Strategies on HIV, Viral Hepatitis and Sexually Transmitted Infections 2022-2030.

Civil society organisations and communities of people living with HIV/AIDS (PLWHA) look to WHO to mobilise political will and provide strategic direction to tackle the drivers of HIV-related death and suffering.

We have taken for granted that AIDS would disappear with the increased coverage of antiretroviral therapy (ART). However, even in countries with high ART coverage, life-threatening opportunistic infections continue. We still face resistance from national HIV programmes and global health actors to investing in diagnosing and treating life-threatening opportunistic infections (most notably, tuberculosis and cryptococcal meningitis etc.) and providing hospitalisation and care to PLHIVs critically ill with AHD/AIDS.

I. Comments regarding the Draft Global Health Sector Strategies

1. Urgency and visibility in addressing HIV-related deaths

WHO should recognise that HIV-related mortality is neglected and that AHD/AIDS-specific interventions need to be scaled up as part of national HIV programmes. While the document strikes a note of alarm about new HIV infections, there is nothing similar for AIDS deaths. For example, the section highlighting that HIV-related deaths have been reduced “to their lowest since 1994” (page 3) gives the impression that there is not much more to do and ignores the fact that the 2020 target to reduce AIDS deaths to 500,000 annually has been missed. WHO should express concern and urgency about the specific reasons that people continue to die of AIDS and outline how concretely countries, programmes, and communities can end AIDS deaths by naming specific targets and indicators linked to the main killers of people with HIV (PLHIV).

Just as we cannot allow AIDS – or AIDS deaths – to be invisible, we cannot silently tolerate the suffering from TB and opportunistic infections like cryptococcal meningitis that are responsible for hundreds of thousands of deaths each year. In the Strategies document, any mention of reducing deaths or major causes of mortality should also specifically cite cryptococcal meningitis and severe bacterial infections (page 5, box 1.3; page 14 table 2.1 and Action 44; Page 33, boxes 4.1 and 4.2).

2. AIDS/AHD related impact and coverage targets

The document falls short on putting forth strategies to better address AHD/AIDS. In particular, it is shocking that cryptococcal meningitis (CM), the second-leading cause of HIV-related deaths (14%), is mentioned only once and there are no suggestions to monitor and report on CM incidence or deaths and no defined targets to track and increase CM prevention, diagnosis, and treatment coverage.

The Strategies document needs to go beyond “ACTION 44: Advanced HIV disease. Provide care for adults and children with advanced HIV disease” (page 37). Specifically, we ask that WHO embrace and promote in the Strategies document HIV targets for 2025 and 2030 (page 33) the recommended CM impact and coverage targets developed by a coalition of experts, implementers, and civil society:[^1]

• Impact: Reduce CM deaths by 50% by 2025 and 90% by 2030 from 2020 baseline
• Coverage: Percentage of adults with AHD/AIDS with a CrAg result: 80% by 2025 and 90% by 2030
• Coverage: Percentage of adults with CM treated with a flucytosine-containing induction treatment regimen: 80% by 2025 and 90% by 2030

Given its importance as a gateway for managed AHD/AIDS care, it is critical that WHO include a coverage target for people living with HIV to receive a CD4 test result. The experts mentioned above recommend the target of 90% by 2025 and 95% by 2030.

The Strategies document mentions some key interventions needed to reduce TB-related morbidity and mortality among PLHIV, but does not include sufficient detail on the specific interventions needed. In ACTION 48, the document should specify:

• “systematic screening for tuberculosis symptoms and the use of WHO-recommended TB screening tools including X-ray, rapid molecular tests, and C-reactive protein among PLHIV”
• “rapid TB diagnosis using urine-based point-of-care LF-LAM testing in combination with rapid molecular testing”
• “tuberculosis preventive treatment prioritizing rifapentine-based 3HP and 1HP”
• “treatment of tuberculosis and drug-resistant tuberculosis using the the latest regimens for treating drug-sensitive and drug-resistant TB (e.g., the four-month rifapentine- and moxifloxacin-containing regimen for drug-sensitive TB, and all-oral, bedaquiline-based regimens for drug-resistant TB)”

Given the critical importance of rapid point-of-care TB diagnosis and immediate TB treatment initiation for reducing HIV-related mortality among PLHIV with AIDS, the WHO should include a coverage indicator of TB diagnostic testing using both LF-LAM and rapid molecular testing among PLHIV who present to care with signs and symptoms of TB, severe illness, or AIDS with targets of 90% by 2025 and 95% by 2030. Furthermore, impact indicator 22 should disaggregate mortality caused by TB, hepatitis B, and hepatitis C to support disease-specific monitoring and accountability.

In addition to CM, other major drivers of AHD/AIDS deaths need to be named and specific targets developed. Kaposi’s sarcoma, for example, remains a neglected HIV- related cancer with no updated international guidance and treatments rarely included in the public sector.

3. AIDS/AHD services and package of care at the primary health care level

In addition to addressing the lack of urgency and concrete targets, we would like to see WHO emphasize the promotion of the package of care at the primary health care level to prevent, detect, and treat AIDS/AHD. This includes essential medical tools and services such as CD4 testing, LF-LAM, CrAG, 1HP/3HP for TB preventive therapy (TPT), and treatment therapies for bacterial and fungal infections.[^2] This package should be detailed and more prominent in the Strategies document (and specifically need to be added to page 39).

4. Enablers

Finally, decentralization of AHD management must be a cornerstone of this strategy in order to bring quality clinical care closer to communities at high risk of preventable death. Equally important is the need for the draft Strategy on the AIDS/AHD sections to emphasise the need for community-led treatment literacy programs and community- led monitoring initiatives. The Strategies document should place emphasis on renewed attention to addressing stigma and discrimination that prevents access to care and hospitalisation and basic procedures such as lumbar punctures for PLHIV affected by AIDS and needing critical care. Equally important is the need to focus on preventing stockouts and ensuring sustainable, predictable access to basic essential medicines to PLHIVs at health facilities for prevention of OIs.

2. Requests for WHO leadership and concrete actions to address AHD/AIDS

We ask that WHO:

• Provide and garner more attention for, the goal of reducing AIDS deaths, suffering, and the main drivers of deaths, notably tuberculosis and cryptococcal meningitis, including on World AIDS Day 2021[AB1]
• Strongly encourages countries to align protocols with AHD/AIDS guidance, including forthcoming CM treatment recommendations
• Address the fact that cryptococcal meningitis has been unaddressed and undercounted by developing recommendations for clear quantification and monitoring of cryptococcal meningitis incidence, hospitalizations, and death, as well as diagnosis and treatment coverage indicators and targets by developing recommendations for AHD/AIDS indicators and including these additions to its databases
• Work with PEPFAR and the Global Fund to make a plan for national and global quantification and monitoring of cryptococcal meningitis and other opportunistic infections
• Endorse the “Framework to End CM Deaths by 2030” or develop an alternative that WHO will champion
• Convene global health actors and work with us to seek concrete commitments, starting with a consensus statement in support of the “Framework to End CM Deaths by 2030”
• Develop recommendations for National Strategic Plans (NSPs) to better address AIDS and advanced HIV disease, including impact and coverage targets
• Develop a costed checklist of tools and services needed at the primary health care to prevent, detect, and treat AIDS and opportunistic infections
• Mobilize resources and political will for regional semi-annual meetings of Ministries of Health (MOHs) and heads of national HIV programmes in SSA, WCA, SEA, etc. on progress and challenges of reducing AHD/AIDS sickness and deaths (with a rotating MOH as the host government)

We also ask that WHO prioritise reducing AIDS illnesses and deaths in its engagement with and guidance and technical assistance to countries in order to achieve the following objectives:

• National governments endorse a statement of commitment towards measuring, reporting, and meeting AHD/AHD targets, including those for cryptococcal meningitis (CM)
• National governments adopt AHD/AIDS targets in National Strategic Plans, agree to report on AHD/AIDS indicators, and align AHD/AIDS guidelines and protocols with WHO recommendations
• National governments plan to provide package of care at the PHC level to prevent, detect, and treat AHD/AIDS
• National regulatory authorities fast-track approval of submitted dossiers for medications for cryptococcal meningitis and TB

We would like to discuss these issues and requests above with you and your team at your earliest convenience.

Thank you for considering and we look forward to hearing from you.

Sincerely,

Omar Syarif and Wim Vandevelde, PLHIV Stigma Index Programme Manager and Liaison Officer, Global Network of People Living with HIV (GNP +)

Vuyiseka Dubula, PhD, Centre for Civil Society, University of KwaZulu-Natal, South Africa

Dr Jennifer Cohn, Clinical Associate Professor of Infectious Diseases, University of Pennsylvania School of Medicine

Asia Russell, Executive Director, Health GAP

Solange Baptiste, Executive Director, International Treatment Preparedness Coalition (ITPC)

Bactrin Killingo, Strategic Advisor, International Treatment Preparedness Coalition (ITPC)

Amanda Banda, Advocacy Advisor, Médecins Sans Frontières (MSF)

David Branigan, TB Project Officer, Treatment Action Group (TAG)

Sharonann Lynch, O'Neill Institute for National and Global Health Law, Georgetown University

Kenneth Mwehonge, Program Manager, Coalition for Health Promotion and Social Development (HEPS)

Thokozile Phiri Nkhoma, Executive Director Facilitators of Community Transformation (FACT- Malawi)

Wanangwa Sichinga, Communications and Advocacy Officer, FACT-Malawi

[^1]: International Treatment Preparedness Coalition ITPC), CDC Foundation, Médecins Sans Frontières (MSF), St Georges-University of London, University of Minnesota, Drugs for Neglected Diseases Initiative (DNDI), National Institute for Communicable Diseases, Global Action Fund for Fungal Infections ( Gaffi). Ending cryptococcal meningitis deaths by 2030: Strategic framework. 13 May 2021. Available from: https://msfaccess.org/ending-cryptococcal-meningitis-deaths-2030-strategic-framework [^2]: MSF. 20-tool checklist for diagnosing, treating and preventing AIDS: Diagnostic and treatment checklist for the management of HIV and advanced HIV disease in outpatient settings. January 2021. Available from: https://msfaccess.org/20-tool-checklist-diagnosing-treating-and-preventing-aids