Differentiated service delivery-

Advanced HIV disease(DSD)

June/ 2023
 Presentation Outline

 Introduction on DSD Model

 Rational for DSD model implementation
 Classification of DSD models
 Eligibility criteria
 DSD for Advanced HIV Disease
 LF_LAM testing for RVI clients
 Update on Common OI diagnosis and Mx
– Cryptococcal meningitis
– PCP
– CNS Toxoplasmosis
 Introduction-What is differentiated care?

Client-centered:

 Differentiated care is a client- centered approach that simplifies and adapts

HIV services across the cascade to reflect the preferences and expectations of

various groups of people living with HIV

 It reduces unnecessary burdens on the health system.

 The health system can refocus resources to those most in need.

Rationale...

To reach 95-95-95:

» Clients who are not currently on treatment need to access ART within a service

delivery model that meets their needs and expectations.

» Different packages of care are essential to address these diverse needs –it’s

time to deliver differently.

» Differentiated care applies across the HIV continuum to all the 95-95-95

targets
 DSD building blocks
• Differentiated service delivery for HIV treatment is based on
four building blocks
 Classification of DSD models

1. Less intensive DSD models:

 Is intended for clients who are established on ART.
 It includes both facility and community-based approaches.
 It requires less frequent clinic visits and focuses on
education and empowerment of clients.
2. More intensive DSD models:
 Is intended for clients who need close follow up and
frequent clinic visits.
 It includes clients with OI, unsuppressed viral load
adolescents, pregnant women/lactating women and those
with psycho social barriers to adhere and retention.
 Eligibility criteria for less intensive DSD
models

 Patients who are on ART at least six months

 No current illness, which does not include well-controlled
chronic health conditions
 Good understanding of lifelong adherence; adequate
adherence counseling provided (a patient with adherence
of 95% for the last 6 months)
 Evidence of treatment success (at least one suppressed
viral load result (i.e < 50 c/ml) and if no Viral Load result, a
patient with CD4 cell count above 200 cells/millimeter
cubes).
 Eligibility criteria for less intensive DSD
models…
 Children with age greater than five years
 A Patient who doesn’t have current
Opportunistic Infections
 A Patient with no adverse drug reactions and
doesn’t need careful clinical monitoring.
 A Patient who is willing or provide consent to
get the ART service based on his/her preferred
DSD models.
Appointment Spacing Model (ASM/6MMD)

• Stable clients will be appointed every six months for

clinical visit and medication refill.
• Clients in this model should get additional supports
like arrangement of treatment supporter at home
level among their family members
– Arrangement of adherence reminders like alarm and
education on how to maintain the drug quality at
home level.
– Clients should be counseled and encouraged to
disclose their status and to participate in peer support
groups or to be a member of PLHIV associations.
Three Months ARV Dispensing (3MMD)
• Clients who are eligible but not willing to be enrolled
in 6 MMD (ASM) will be appointed every three
months for both clinical visit and medication refill.
• For clients requiring Cotrimoxazole, a 3-6-month
supply should be provided at the same time as ART
pickup. TPT should also be given in multi-month
intervals at the same time as ART pickup.
 Fast Track ARV Drugs Refill Model
• FTAR is one of the facility based Differentiated Service
Delivery Models of HIV care where patients categorized
as stable make clinical visit once every six months but
collect their medication every three months from
pharmacy
• The facility-based fast track system for ART refills can
provide an opportunity for those ASM clients who, for
various reasons, faced difficulty in taking all of the
prescribed six-months of ARV drugs to their home at
once from the ART pharmacy as in the ASM framework.
 Health Extension Professional Managed
Community ART refill group (HEP_CAG)
• Community ART refill groups (CAGs) are groups comprising
of stable clients on ART living in the same
community/locality that have a shared understanding.
• This model is managed by health extension professionals
who already have roles in HIV testing and other HIV service
provision as one of their packages.
• The ART refill is for three months and each CAG will have
one community refill in between the heath facility visits
that will happen every six months.
• Clients can return or referred to the facility at any point in
the cycle for any issues that may arise between scheduled
health facility visits.
 Peer lead community based ART
distribution/Group (PCAD/G
• The peer led Community based ART distribution (PCAD) groups
are groups of PLHIV comprising of stable clients living in the same
community/ locality.
• In PCAD, group members will take turns to pick up ARVs at the
health facility and distribute among the other group members in
the community.
• Each client will get clinical evaluation and lab monitoring service
as per the standard of care package.
• They will manage their own health and take action with the
support of community and facility-based healthcare workers and
this will help to align with the clinical consultation visits at health
facilities as the recommended, in our set up is every six months.
 More intensive DSD models
• DSD for adolescents has three core elements which
include
– ART refill,
– clinical consultation and
– psychosocial support.
• This model is coordinated by trained health
care workers (HCWs), and regularly meet on
weekends and share psychosocial supports.
 DSD for adolescents
• During this peer session, adolescents interact, learn and
share experience among their peers and from
facilitators.
• Understanding the treatment, adherence to treatment
and viral suppression are main parts of their discussion.
• Making the clinical, ARV refill and viral load monitoring
service available over the weekends together with the
psychosocial support program will make comprehensive
HIV service a one stop shopping model for adolescents
living with HIV.
Eligibility criteria for Adolescent clients
on DSD model:
• Adolescent clients who disclosed their HIV status
and willing or provide consent to get the ART
service based on his or her preferred DSD models.
• Health care facility where there is functional
OTZ/pediatric psychosocial support program,
• Adolescents, 10- 19 years, fully disclosed, enrolled
in the pediatric psychosocial support/OTZ program,
• No restriction on stability- including both with
suppressed and unsuppressed viral load test result
 DSD for key population (for FSWs)

» Designing person-centered DSD prevention, testing/linkage,

and treatment models that are attuned to the issues of stigma

and access specific to FSW will be critical to ensuring equity

and achieving HIV epidemic control. 

» Confidentiality clinics and drop in centers (DICs)

 Differentiated Service Delivery (DSD) in
PMTCT

 PMTCT DSD includes the following activities

1. Multi Month Dispensing (3MMD) for PMTCT
2. Point of Care (POC) for VL Testing , among Pregnant /BF
Women
3. Point of Care (POC) EID for HEIs
4. Family Planning integration
DSD for Advanced HIV Disease
All HIV positive patients with CD4 cell count <200
cells/mm3 OR a WHO clinical stage 3 or 4 disease
aged more than five years
All children younger than five years old with HIV are
considered as having advanced HIV disease
For patients with advanced HIV disease, the
frequency of clinical visit is recommended every
month.
 Burden of AHD

In Ethiopia, among adults aged 15-64 years living with HIV,
35.8% had immunosuppression with CD4 count less than 350
cells/mm3
 Among adults who reported they were unaware of their HIV-
positive status, 22.0% had severe immunosuppression—a
CD4 count less than 200 cells/mm3
 33% of newly enrolled adult clients were assessed as
having WHO Stage III or IV at presentation
 A significant proportion of AIDS related deaths are attributed
to advanced HIV Disease.
 TB and CCM are the major causes of AIDS related mortality
 Components to consider when designing a
DSD model for advanced HIV

Consider the building blocks (when, where, who and what) for each of
the following components of a service delivery model for advanced HIV:
– Identifying advanced HIV disease
– Clinical package to screen, prevent and treat
advanced HIV disease
– Rapid ART initiation/ or regimen switch
– Linkage to ongoing care
– Post initiation/ switch follow up
 CD4 count testing criteria to diagnose AHD
and determine eligibility for the AHD package

For new clients initiating ART

• At baseline for all PLHIV.
For those who are treatment experienced:
– Reengaged to treatment after 28 days or greater of ART
interruption.
– Children under five years of age on ART.
–Persistent unsuppressed viral load (two viral load VL
>1,000 within 3-6 months).
Summary of Components of care for people
with advanced HIV disease
 Advanced HIV disease in children

• The major causes of morbidity and mortality among children

living with HIV in low- and middle-income countries are
pneumonia (including P. Jirovecii pneumonia), TB,
bloodstream infections, diarrheal disease, and severe acute
malnutrition.

• The main interventions known to reduce morbidity and

mortality among children living with HIV can be summarized
as screen, treat, optimize, and prevent (STOP) AIDS.
STOP AIDS Approach
STOP AIDS Approach
 Cryptococcal meningitis

Cryptococcal meningitis is one of the most important

opportunistic infections and a major contributor to high
mortality before and after ART is initiated.
• The main reasons for this high death rate include
o Delayed presentation,
o Poor availability of diagnostic treatment facilities
Clinical manifestations
• Fever, malaise, and headache
• Neck stiffness and photophobia, occur in only one-quarter to one-
third of patients
• Some patients experience encephalopathic symptoms, such as
lethargy, altered mentation, personality changes, and memory loss
 Diagnosis

• The opening pressure may be markedly elevated.

• CSF analysis
oProtein 30-150 mg/dl
oWBC 0-100 /mm3 (monocyte)
oCulture positive 95-100%
o Indian ink positive 60-80%
oCryptococcal Ag > 95 % sensitive and specific
 Management of cryptococcal meningitis

Induction phase:- Rapidly clear the organism from the body

• A single high dose (10 mg/kg) of Liposomal Amphotericin B with 14 days
of flucytosine (100 mg/kg per day divided into four doses per day) and
fluconazole (1200 mg/daily for adults; 12 mg/kg per day for children and
adolescents up to a maximum of 800 mg daily) should be used as the
preferred induction regimen.
If Liposomal Amphotericin B is not available:
• A short-course (one-week) induction regimen with Amphotericin B
deoxycholate (1.0 mg/kg per day) and flucytosine (100 mg/kg per day,
divided into four doses per day) followed by 1 week of fluconazole
(1200 mg/day for adults, 12 mg/kg/day for children and adolescents, up
to a maximum dose of 800mg daily
Management of cryptococcal meningitis

If no Amphotericin formulation available:

• Two weeks of Fluconazole (1200 mg daily, 12 mg/kg per day for
children and adolescents) + Flucytosine (100 mg/kg per day, divided
into four doses per day).
If Flucytosine is not available:
• Two weeks of Liposomal Amphotericin B (3–4 mg/kg per day) +
Fluconazole (1200 mg daily, 12 mg/kg per day for children and
adolescents up to a maximum of 800 mg daily).
If Liposomal Amphotericin B and Flucytosine are not
available:
• Two weeks of Amphotericin B deoxycholate (1.0 mg/kg per day) +
Fluconazole (1200 mg daily, 12 mg/kg per day for children and
adolescents up to a maximum of 800 mg daily).
 Consolidation phase

• Ensure disease is fully suppressed

• Fluconazole (400–800 mg daily for adults or 6–12 mg/kg per

day for children and adolescents up to a maximum of 800 mg
daily) is recommended for the consolidation phase (for eight
weeks following the induction phase).
 Maintenance phase(or secondary prophylaxis)

• Prevents recurrence of disease after treatment; this phase is

also known as secondary prophylaxis
• Fluconazole (200 mg daily for adults or 6 mg/kg per day for
adolescents and children) is recommended for the
maintenance phase.
• Discontinuation of maintenance treatment will be when
• patients are stable
• Adherent to ART and anti-fungal maintenance treatment
for at least one year and
• Have a CD4 cell count of greater than or equal to 200
cells/mm3 (two measurements six months apart).
 Timing of ART initiation for patient with Cryptococcal
meningitis

• Immediate ART initiation is not recommended among adults,

adolescents and children living with HIV who have
cryptococcal meningitis because of the risk of increased
mortality and should be deferred 4–6 weeks from the
initiation of antifungal treatment.
• Paradoxical cryptococcal immune reconstitution
inflammatory syndrome occurs among 10–50% of people
with cryptococcal disease initiating ART and is associated
with high mortality
Timing of ART initiation for patient with
Cryptococcal meningitis
 Fluconazole Preventive therapy (FPT)

Who is eligible for FPT:

–Blood-CrAg (+)ve with out symptom and sign of CCM
– When cryptococcal antigen screening is not available, fluconazole
primary prophylaxis should be given to adults and adolescents living
with HIV who have a CD4 cell count of < 100 cells/mm3.

What will be given as FPT:

– Treat with Fluconazole 800mg daily for two weeks
– Initiate/re-initiate ART after 2wks of fluconazole then
– Fluconazole 400mg daily for 8 weeks, then
– Fluconazole 200 mg daily until
 Peculiarities of TB in AHD

 Increased susceptibility to active TB

 Typical TB symptoms are mostly absent (bizarre Sx)

 More common to have disseminated and/or extra pulmonary TB

 Even with pulmonary TB:

- CXR findings may be minimal/atypical or even normal
- Dry cough or no cough, difficult to get good quality sample for lab
investigation

 Sensitivity of lab tests from sputum sample decrease with increasing

immunosuppression
 TB dx by LF_LAM

Lipoarabinomannan (LAM) is;

• Released from metabolically active or those that are being degraded
bacteria
✓ It has structural epitopes that are unique to MTB
✓LAM is found in blood and sputum as well as in urine but

 WHO approved only urine for TB diagnostic test by Urine LF-LAM test

LAM levels in urine are known to be elevated in people with HIV–TB co-
infection, and increase as CD4 counts decrease
 Criteria for eligibility for Urine LF-
LAM testing


All PLHIV with signs and symptoms of TB (pulmonary and/or extra-pulmonary)
or
Seriously ill or

Irrespective of signs and symptoms of TB who have a CD4 cell count of less than
• Out patient setting: CD4≤100 cells/mm3
• Inpatient Settings: CD4< 200 cells/mm3

All under five children
 Pneumocystis pneumonia (PCP)

• Pneumocystis pneumonia is caused by Pneumocystis

jiroveci
Clinical presentations
History
• Insidious onset of low-grade fever, dry cough, dyspnea exacerbated by
exertion.
Physical examination reveals
• Fever, Tachypnea & tachycardia, scattered rales in the lungs, but
examination of the lungs can appear normal in some patients.
In children highest incidence is seen between 2-6 months of age and is
characterized by abrupt onset of fever, tachypnea, dyspnea and cyanosis
 Diagnosis of PCP

Presumptive diagnosis of PCP is based on clinical judgment and

typical chest X-ray finding revealing a peri-hilar interstitial infiltration
with tendency to spread outwards
Note that the chest X-ray can be normal in 20% of patients
Definitive diagnosis of PCP is based on demonstration of the organism
from an induced sputum sample using special stains like Giemsa stain
Treatment
Use Trimethoprim 15-25 mg/kg, three or four times daily for 21 days.
In severely ill patients with marked respiratory distress prednisolone
has to be given simultaneously
 Toxoplasmic encephalitis (TE)

• Toxoplasmic encephalitis (TE) is caused by the

protozoan Toxoplasma gondii.
• Disease appears to occur almost exclusively because
of reactivation of latent tissue cysts
 Clinical Manifestations

The most common clinical presentation of T. gondii infection is

 Focal encephalitis with headache, confusion, or motor weakness and
fever.
 Patients may also present with non-focal manifestations, including only
non-specific headache and psychiatric symptoms.
 Focal neurological abnormalities may be present on physical
examination, and
 In the absence of treatment, disease progression results in seizures,
stupor, and coma.
 Diagnosis
• HIV-infected patients with TE are almost uniformly
seropositive for anti-toxoplasma immunoglobulin G
(IgG) antibodies.
• Anti-toxoplasma immunoglobulin M (IgM) antibodies
usually are absent.
• Diagnosis of CNS toxoplasmosis requires
o a compatible clinical syndrome;
o identification of one or more mass lesions by CT, MRI, or
other radiographic testing; and
odetection of the organism in a clinical sample..
 Diagnosis…
• In the absence of imaging support, empirical
treatment is justified when patients present with
focal neurological findings and the CD4 count is <
200 cells μL.
• Failure to respond to conventional therapy, based on
presumptive clinical diagnosis within a week or two
of initiation of therapy, suggests the diagnosis to be
unlikely
 Treatment

• Trimethoprim/sulfamethoxazole 80/400, oral, 4 tablets 12 hourly

for 28 days, followed by 2 tablets 12 hourly for 3 months in adults.

• Children: 10mg of trimethoprim + 50mg of sulfamethoxazole/kg

per dose every 12 hours for 28 days followed by maintenance
therapy at 50% reduced dosage for three months.
• Adjunctive corticosteroids should be used for patients with
radiographic evidence of midline shift, signs of critically elevated
intracranial pressure or clinical deterioration within the first 48
hours of therapy
• Secondary prophylaxis: use co-trimoxazole 960mg daily for
adults
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