Modern ART for South Africa

What is advanced HIV disease (AHD)?

AHD means you have or could get certain illnesses that happen when someone’s CD4 cell count is low. All children under five have AHD.

CD4 cells are infection-fighting white blood cells. The fewer CD4 cells you have, the more you are at risk of illnesses.

In South Africa almost a third of people living with HIV start treatment with a low CD4 count.

AHD & CD4

Everyone diagnosed with HIV or re-entering care should get a CD4 test.

AHD is a CD4 count below 200 cells /mm³ for adults, adolescents and children over five. All children under five have AHD.

The risk of death is higher with a low CD4 count, especially below 100 cells/mm³.

A CD4 count below 50 cells/mm³ is severely advanced disease.

What are the danger signs?

A seriously ill adult or adolescent might have:

• Shortness of breath
• Rapid heart beat
• Unable to walk without help
• High temperature

A seriously ill child might have:

• Sleepiness
• Unconsciousness
• Convulsions (violent, irregular movement)
• Unable to drink or breastfeed
• Repeated vomiting
• High temperature

What is the best way to prevent AHD?

The best way to prevent AHD is to start ART when your CD4 count is high.

Everyone should start ART when they are diagnosed, whatever their CD4 count.

For more information about HIV treatment and CD4 see our section on Starting ART.

What if your CD4 count is already low?

Starting ART right away gives you the best chance of getting better and avoiding illnesses, even with a very low CD4 count.

People with AHD need a special package of care, including counselling, ART and medicines to prevent or treat other infections – and information so they are comfortable with their decision to start ART.

Tuberculosis (TB)

TB, a bacterial infection, is the leading cause of illness and death among people living with HIV – especially people with AHD and those who are not yet taking ART. Symptoms include coughing, fever, night sweats and weight loss.

People diagnosed with TB should start TB treatment before starting (or re-starting) ART.

For more information about TB, see our section on ART & TB.

TB prevention and testing

Everyone starting ART will be screened for TB. Adults, adolescents and children who do not have TB should be offered TB preventive treatment.

All with TB symptoms should get a sputum test called Xpert MTB/RIF. Adults, adolescents and children who are very ill and/or have a CD4 count below 100 cells/mm³ should get a urine test called TB-LAM.

Severe Bacterial Infections (SBI)

People with AHD often have severe bacterial infections in the bloodstream, nose, mouth, throat, voice box, windpipe or lungs, the brain and spinal cord or the stomach and intestine.

Cotrimoxazole protects against some but not all SBI. People living with HIV in places where SBI or malaria are common should get lifelong cotrimoxazole, whatever their CD4 count. Dapsone is available for people who react to cotrimoxazole.

Cryptococcal Meningitis

Cryptococcal meningitis is a serious fungal infection of the brain and spinal cord.

Symptoms are headache, fever, nausea, vomiting, light sensitivity, confusion and behavior changes.

Adults and adolescents with a CD4 count under 200 cells/mm³ should have a CrAg test and a lumbar puncture if necessary; if positive, depending on how bad the disease, fluconazole alone or in combination other medicines (amphotericin B and flucytosine) will be needed for treatment. 

Pneumocystis Jirovecii Pneumonia (PCP)

PCP, a fungal infection, is a leading cause of illness and death among adults, adolescents and children with AHD. Symptoms are: cough, chest pain, difficulty breathing, fever and tiredness. It can be prevented and treated with cotrimaxozole.

Toxoplasmosis

Toxoplasmosis, a common infection caused by a parasite, can make people very ill if their CD4 count is under 200 cells/mm³.

Symptoms may be similar to those of TB, cryptococcal meningitis, or pneumocystis, or headache, confusion, seizures, blurry vision, and poor coordination. Cotrimaxozole can be used to prevent it and for treatment (as well as other options).

Cytomegalovirus (CMV)

People with a CD4 cell count below 50 cells/mm³ are at risk for CMV retinitis, an eye infection.

Symptoms are: blurred vision, blind spots, peripheral vision loss, ‘floaters’ (small white specks) and light flashes. Untreated CMV retinitis causes blindness. ART can prevent CMV retinitis. It can be treated with medicine that is taken orally or injected into the eye.

Staying healthy

Getting tested for HIV, starting ART and taking it every day can prevent HIV from weakening the immune system.

For people with advanced HIV, taking ART can help it to recover, and other medicines can protect you from opportunistic infections.